Provider Demographics
NPI:1558537209
Name:PRICE, JENNA (MOT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:PRICE
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 BRAZELL LN
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6779
Mailing Address - Country:US
Mailing Address - Phone:904-955-1032
Mailing Address - Fax:912-265-0041
Practice Address - Street 1:1204 HOSPITALITY AVE STE E
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6811
Practice Address - Country:US
Practice Address - Phone:912-996-2069
Practice Address - Fax:912-265-0041
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2017-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006924225XP0200X
FLOTT13091225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty