Provider Demographics
NPI:1114370020
Name:FINE, JENNIFER MICHELLE (BS, MOT R//L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:FINE
Suffix:
Gender:F
Credentials:BS, MOT R//L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 LINDSEY LN
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-1635
Mailing Address - Country:US
Mailing Address - Phone:912-510-6104
Mailing Address - Fax:912-882-6137
Practice Address - Street 1:70 LINDSEY LN
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558
Practice Address - Country:US
Practice Address - Phone:912-510-6104
Practice Address - Fax:912-882-6137
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC013633225X00000X
GAOT007252225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist