MEDICARE: JENNIFER NICOLE DACHTYL OTR/L

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	5159	AZ

General Provider Information

NPI Number	:	1952664070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER NICOLE DACHTYL OTR/L

Provider Business Mailing Address
First Line	:	2524 S EL PARADISO
Second Line	:	UNIT 118
City	:	MESA
State	:	AZ
Zip	:	85202-7459
Country	:	US
Telephone Number	:	586-945-1117
Fax Number	:

Provider Business Practice Location Address
First Line	:	2524 S EL PARADISO
Second Line	:	UNIT 118
City	:	MESA
State	:	AZ
Zip	:	85202-7459
Country	:	US
Telephone Number	:	586-945-1117
Fax Number	:

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

Provider Enumeration Date	:	06/22/2012
Last Update Date	:	06/22/2012

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