Provider Demographics
NPI:1407197163
Name:JENKINS, KELLY D (OT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:JENKINS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5334 MEADOW LANE CT
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1469
Mailing Address - Country:US
Mailing Address - Phone:440-934-8987
Mailing Address - Fax:
Practice Address - Street 1:5334 MEADOW LANE CT
Practice Address - Street 2:
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44035-1469
Practice Address - Country:US
Practice Address - Phone:440-934-8987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT.007456225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH180600Medicare PIN