Provider Demographics
NPI:1528543097
Name:JENNINGS, SHELBY BROOKE (OT)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:BROOKE
Last Name:JENNINGS
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 1:20211 SUGARLOAF RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5216
Mailing Address - Country:US
Mailing Address - Phone:770-314-1113
Mailing Address - Fax:
Practice Address - Street 1:7035 SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1177
Practice Address - Country:US
Practice Address - Phone:803-749-0924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
SC5404225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist