Healthcare Provider Details

I. General information

NPI: 1336754498
Provider Name (Legal Business Name): JEAN IHLE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 SHELL RD
MILL VALLEY CA
94941-1551
US

IV. Provider business mailing address

49 SHELL RD
MILL VALLEY CA
94941-1551
US

V. Phone/Fax

Practice location:
  • Phone: 415-902-6132
  • Fax:
Mailing address:
  • Phone: 415-902-6132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2317
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number2317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: