Provider Demographics
NPI:1164798211
Name:ACREE, JENNIFER ANN (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:ACREE
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:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:MONGO
Mailing Address - State:IN
Mailing Address - Zip Code:46771-0021
Mailing Address - Country:US
Mailing Address - Phone:260-336-2620
Mailing Address - Fax:
Practice Address - Street 1:770 N 075 E
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-9359
Practice Address - Country:US
Practice Address - Phone:260-463-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001421A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant