Provider Demographics
NPI:1235142589
Name:COLEMAN, JENNIFER L (OTR)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 AUGUSTA RD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-6320
Mailing Address - Country:US
Mailing Address - Phone:803-926-7204
Mailing Address - Fax:
Practice Address - Street 1:1900 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5932
Practice Address - Country:US
Practice Address - Phone:803-926-7204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2387225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ341258450Medicare PIN