Provider Demographics
NPI:1235992272
Name:MANDERNACH, JENNA ANN (OTRL)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ANN
Last Name:MANDERNACH
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 TITTABAWASSEE RD APT F
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-1073
Mailing Address - Country:US
Mailing Address - Phone:810-629-0530
Mailing Address - Fax:
Practice Address - Street 1:400 ROUNDS DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1724
Practice Address - Country:US
Practice Address - Phone:810-629-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013758225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist