Provider Demographics
NPI:1013229467
Name:LARUE, JENNIFER (OTRL)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LARUE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 W HIGHLAND RD # RS
Mailing Address - Street 2:SUITE 500-600
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-2168
Mailing Address - Country:US
Mailing Address - Phone:517-376-4831
Mailing Address - Fax:517-376-4833
Practice Address - Street 1:138 W HIGHLAND RD # RS
Practice Address - Street 2:SUITE 500-600
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-2168
Practice Address - Country:US
Practice Address - Phone:517-376-4831
Practice Address - Fax:517-376-4833
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006346225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201006346OtherOCCUPATIONAL THERAPIST LICENSE