Healthcare Provider Details

I. General information

NPI: 1730424565
Provider Name (Legal Business Name): JEFFREY BRYAN SISON MARTINEZ OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2012
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 GINSENG CT
HENDERSON NV
89052-5008
US

IV. Provider business mailing address

1024 GINSENG CT
HENDERSON NV
89052-5008
US

V. Phone/Fax

Practice location:
  • Phone: 818-645-6082
  • Fax:
Mailing address:
  • Phone: 818-645-6082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number12-0281
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number12-0281
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number12-0281
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number12-0281
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: