Provider Demographics
NPI:1104035583
Name:TETREAULT, JENNIFER JEAN (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEAN
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 LISKA RD
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-1411
Mailing Address - Country:US
Mailing Address - Phone:860-706-7758
Mailing Address - Fax:
Practice Address - Street 1:51 APPLEGATE LN
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-1201
Practice Address - Country:US
Practice Address - Phone:860-568-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000436224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant