Provider Demographics
NPI:1033277702
Name:PATRICK, JENNIFER CHERESE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:CHERESE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:CHERESE
Other - Last Name:PATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:202 DARLINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-4602
Mailing Address - Country:US
Mailing Address - Phone:334-333-3002
Mailing Address - Fax:
Practice Address - Street 1:430 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1616
Practice Address - Country:US
Practice Address - Phone:334-677-6955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2286174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2286OtherOCCUPATIONAL THERAPY LIC