Provider Demographics
NPI:1013180983
Name:SEIDL, JACQUELINE ANN PROFFITT (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN PROFFITT
Last Name:SEIDL
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 1:2201 BAUER DR
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4814
Mailing Address - Country:US
Mailing Address - Phone:808-638-2892
Mailing Address - Fax:
Practice Address - Street 1:2201 BAUER DR
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4814
Practice Address - Country:US
Practice Address - Phone:808-638-2892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOT-725225X00000X
WI4529-026225X00000X
VA0119004197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist