Provider Demographics
NPI:1093297715
Name:PENNOCK, JEFFREY AARON I (OTR)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:AARON
Last Name:PENNOCK
Suffix:I
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15071 SHELL POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-1639
Mailing Address - Country:US
Mailing Address - Phone:239-454-2256
Mailing Address - Fax:239-466-1240
Practice Address - Street 1:15071 SHELL POINT BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-1639
Practice Address - Country:US
Practice Address - Phone:239-454-2256
Practice Address - Fax:239-466-1240
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9358225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist