Provider Demographics
NPI:1073930756
Name:FICKLER, JENNIE L (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:L
Last Name:FICKLER
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 1:300 BROWNSTONE DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1710
Mailing Address - Country:US
Mailing Address - Phone:937-286-6300
Mailing Address - Fax:
Practice Address - Street 1:2701 N ROCKY POINT DR
Practice Address - Street 2:SUITE 650
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-5917
Practice Address - Country:US
Practice Address - Phone:800-892-0640
Practice Address - Fax:800-892-0648
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04089224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant