Provider Demographics
NPI:1902116676
Name:LINDQUIST, JERRY ERNEST (PHD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ERNEST
Last Name:LINDQUIST
Suffix:
Gender:M
Credentials:PHD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8699 HOLDER ST
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3614
Mailing Address - Country:US
Mailing Address - Phone:714-563-6556
Mailing Address - Fax:714-821-5683
Practice Address - Street 1:8699 HOLDER ST
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3614
Practice Address - Country:US
Practice Address - Phone:714-563-6556
Practice Address - Fax:714-821-5683
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11789103T00000X
CAOT 5173225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist