Provider Demographics
NPI:1861269243
Name:DUNIVAN, JACQUELINE M (COTA/L)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:DUNIVAN
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 1:22396 E NEBO HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-8018
Mailing Address - Country:US
Mailing Address - Phone:417-684-7393
Mailing Address - Fax:
Practice Address - Street 1:5195 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-6406
Practice Address - Country:US
Practice Address - Phone:417-684-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009019115224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant