Healthcare Provider Details

I. General information

NPI: 1417082256
Provider Name (Legal Business Name): JEAN VIRNIG OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 S ALMA SCHOOL RD STE 130
MESA AZ
85210-3056
US

IV. Provider business mailing address

2936 E INDIAN SCHOOL RD APT C319
PHOENIX AZ
85016-6369
US

V. Phone/Fax

Practice location:
  • Phone: 480-902-0771
  • Fax: 480-967-0804
Mailing address:
  • Phone: 423-544-6699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT436
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT436
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5568
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: