1790254852 NPI number — JENNIFER MAZE HORTON OTD

Table of content: JENNIFER MAZE HORTON OTD (NPI 1790254852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790254852 NPI number — JENNIFER MAZE HORTON OTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HORTON
Provider First Name:
JENNIFER
Provider Middle Name:
MAZE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790254852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 N ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANBY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97013-3519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-263-8903
Provider Business Mailing Address Fax Number:
503-266-8632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27501 SW 95TH AVE STE 960
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILSONVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97070-7713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-855-3223
Provider Business Practice Location Address Fax Number:
503-266-8632
Provider Enumeration Date:
11/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  410426 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410426 . This is a "LICENSED OCCUPATIONAL THERAPY" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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