Provider Demographics
NPI:1043845068
Name:RIECKEN, JASMINE DANIELLE-EVANS (OTR)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:DANIELLE-EVANS
Last Name:RIECKEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:DANIELLE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2305
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80901-2305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5446 N ACADEMY BLVD STE 204
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3669
Practice Address - Country:US
Practice Address - Phone:719-598-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0006339225XP0200X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics