Provider Demographics
NPI:1245567882
Name:COLVIN, JENNICA NICOLE (OTR)
Entity Type:Individual
Prefix:
First Name:JENNICA
Middle Name:NICOLE
Last Name:COLVIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JENNICA
Other - Middle Name:NICOLE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:610-944-9782
Mailing Address - Fax:610-438-2024
Practice Address - Street 1:4415 RIO D ORO
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78233-6748
Practice Address - Country:US
Practice Address - Phone:210-651-3339
Practice Address - Fax:210-651-3339
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110631225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist