Healthcare Provider Details

I. General information

NPI: 1598434003
Provider Name (Legal Business Name): JENNIFER AZARES HIGH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER LOURDES FERALES AZARES OTR/L

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 TERRACINA BLVD
REDLANDS CA
92373-4845
US

IV. Provider business mailing address

1422 REDWOOD ST
BEAUMONT CA
92223-3136
US

V. Phone/Fax

Practice location:
  • Phone: 909-793-2271
  • Fax:
Mailing address:
  • Phone: 760-408-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number2799
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: