Provider Demographics
NPI:1164981692
Name:LUTHER, JENNA CATHERINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:CATHERINE
Last Name:LUTHER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 TREE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-2885
Mailing Address - Country:US
Mailing Address - Phone:727-259-9325
Mailing Address - Fax:
Practice Address - Street 1:22 BUFORD VILLAGE WAY STE 229
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-8846
Practice Address - Country:US
Practice Address - Phone:670-482-6100
Practice Address - Fax:770-932-5684
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007324225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAXXXXXXMedicaid