Healthcare Provider Details

I. General information

NPI: 1184763823
Provider Name (Legal Business Name): JENNIFER COLLEEN WHITAKER MOT R L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 WEST THOMPSON RANCH
EL MIRAGE AZ
85335
US

IV. Provider business mailing address

8556 W SUNNYSLOPE LN
PEORIA AZ
85345-5362
US

V. Phone/Fax

Practice location:
  • Phone: 623-523-8487
  • Fax:
Mailing address:
  • Phone: 623-523-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3202
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: