Provider Demographics
NPI:1578208112
Name:STADALSKY, JENNIFER M (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:STADALSKY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:MCGRAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:9565 HIGHWAY 78 STE 102
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4118
Mailing Address - Country:US
Mailing Address - Phone:843-569-4546
Mailing Address - Fax:843-569-4535
Practice Address - Street 1:9565 HIGHWAY 78 STE 102
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4118
Practice Address - Country:US
Practice Address - Phone:843-569-4546
Practice Address - Fax:843-569-4535
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1798225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1798OtherSTATE LICENSE