Provider Demographics
NPI:1568793230
Name:BASTIAN, JENNIFER L (MS, OTR)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:L
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 DRIFTWOOD DR S APT 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6045
Mailing Address - Country:US
Mailing Address - Phone:317-439-8102
Mailing Address - Fax:
Practice Address - Street 1:11550 N MERIDIAN ST STE 312
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4562
Practice Address - Country:US
Practice Address - Phone:317-815-0781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003827A225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics