Provider Demographics
NPI:1235331166
Name:WILSON, JENNIFER LYNN (OTAL)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTAL
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:INSTASI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1048 UNION ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:700 MT HOPE AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5680
Practice Address - Country:US
Practice Address - Phone:207-941-2952
Practice Address - Fax:207-941-2955
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA1514224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant