MEDICARE: JENNIFER WILLKOMM OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	10640	CA

General Provider Information

NPI Number	:	1184192759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER WILLKOMM OTR

Provider Business Mailing Address
First Line	:	PO BOX 428
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93448-0428
Country	:	US
Telephone Number	:	805-478-2576
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 SIERRA DR
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2228
Country	:	US
Telephone Number	:	805-904-0016
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2018
Last Update Date	:	11/13/2018

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Directions to “ JENNIFER WILLKOMM OTR” Practice Location

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