Provider Demographics
NPI:1447649496
Name:BRICKEY, JENNIFER (COTA/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BRICKEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7252
Mailing Address - Country:US
Mailing Address - Phone:755-388-4412
Mailing Address - Fax:575-597-2809
Practice Address - Street 1:1318 E 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7252
Practice Address - Country:US
Practice Address - Phone:575-388-4412
Practice Address - Fax:575-597-2809
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NM2525224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant