Individual
MS. JACKE KHANTIVONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OTR/L
Contact information
Practice address
1247 S RACE ST, DENVER, CO 80210-1817
(860) 306-1384
Mailing address
1247 S RACE ST, DENVER, CO 80210-1817
(860) 306-1384
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
003380
CT
225X00000X
Occupational Therapist
Primary
2191
CO
Other
Enumeration date
01/14/2009
Last updated
08/31/2010
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