Provider Demographics
NPI:1265325302
Name:CANCHOLA, JENNIFER M (COTA/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:CANCHOLA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:TAIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50928 DARTMOOR DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1114
Mailing Address - Country:US
Mailing Address - Phone:586-360-5135
Mailing Address - Fax:586-360-5135
Practice Address - Street 1:38257 MOUND RD STE 200
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3466
Practice Address - Country:US
Practice Address - Phone:586-722-7524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008007224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant