Provider Demographics
NPI:1316572225
Name:CLOUGHERTY, JEAN (OTA)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:CLOUGHERTY
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 POTTER HILL RD UNIT 104
Mailing Address - Street 2:
Mailing Address - City:GILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03249-6864
Mailing Address - Country:US
Mailing Address - Phone:603-860-7431
Mailing Address - Fax:
Practice Address - Street 1:85 MAIN ST STE 311
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1500
Practice Address - Country:US
Practice Address - Phone:603-481-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0037224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant