Healthcare Provider Details

I. General information

NPI: 1629554100
Provider Name (Legal Business Name): RAELYNN JENSEN MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS RAELYNN PEREZ

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 OURAY RD NW
ALBUQUERQUE NM
87120-1381
US

IV. Provider business mailing address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-836-0023
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.0007012
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number403238
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10884539-4201
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT4538
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: