Provider Demographics
NPI:1174111256
Name:VILLANUEVA, JENNELYN LIANG (OTR/L)
Entity type:Individual
Prefix:
First Name:JENNELYN
Middle Name:LIANG
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14335 IBEX AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-4961
Mailing Address - Country:US
Mailing Address - Phone:310-801-2538
Mailing Address - Fax:
Practice Address - Street 1:14335 IBEX AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-4961
Practice Address - Country:US
Practice Address - Phone:310-801-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21856225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA85-3327339OtherIRS