Healthcare Provider Details

I. General information

NPI: 1639374739
Provider Name (Legal Business Name): JENNIFER-ANN SALES COATES OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER-ANN CASTANEDA SALES OTD

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20041 RIVERSIDE COMMONS PLZ
ASHBURN VA
20147-5151
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 703-574-3010
  • Fax: 703-810-5323
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-968-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056008044
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119010428
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: