Provider Demographics
NPI:1376046540
Name:ANDERSON, JENNIFER ERNESTINE (MOT, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ERNESTINE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 43RD ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1401
Mailing Address - Country:US
Mailing Address - Phone:516-330-1889
Mailing Address - Fax:
Practice Address - Street 1:900 INTERVALE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-4240
Practice Address - Country:US
Practice Address - Phone:646-951-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012039225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist