Provider Demographics
NPI:1326487117
Name:JENNISON, CHERIE AUTUMN (OTR/L)
Entity Type:Individual
Prefix:
First Name:CHERIE
Middle Name:AUTUMN
Last Name:JENNISON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-3024
Mailing Address - Country:US
Mailing Address - Phone:208-489-5700
Mailing Address - Fax:208-489-4077
Practice Address - Street 1:207 W GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-3024
Practice Address - Country:US
Practice Address - Phone:208-489-5700
Practice Address - Fax:208-489-4077
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1166225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist