MEDICARE: JENNA RIESE MIXON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	27193	FL

General Provider Information

NPI Number	:	1871429225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA RIESE MIXON OTR/L

Provider Business Mailing Address
First Line	:	122 LAKE DR
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33548-6145
Country	:	US
Telephone Number	:	423-763-3722
Fax Number	:

Provider Business Practice Location Address
First Line	:	13907 N DALE MABRY HWY STE 214
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-2411
Country	:	US
Telephone Number	:	877-540-1201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2026
Last Update Date	:	06/23/2026

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