Provider Demographics
NPI:1487043105
Name:GENTRY, JENNIFER ANNE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:GENTRY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-4446
Mailing Address - Country:US
Mailing Address - Phone:903-794-2705
Mailing Address - Fax:903-793-1203
Practice Address - Street 1:1315 WALNUT ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-4446
Practice Address - Country:US
Practice Address - Phone:903-794-2705
Practice Address - Fax:903-793-1203
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213068224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021289601Medicaid