Provider Demographics
NPI:1497854087
Name:AU, JENNIFER (OT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:AU
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 1:761 COMMONWEALTH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-3660
Mailing Address - Country:US
Mailing Address - Phone:404-728-9766
Mailing Address - Fax:404-728-9166
Practice Address - Street 1:1244 CLAIRMONT RD
Practice Address - Street 2:SUITE 224
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1259
Practice Address - Country:US
Practice Address - Phone:404-728-9766
Practice Address - Fax:404-728-9166
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003439225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT003439OtherLICENSE NUMBER