Provider Demographics
NPI:1609061050
Name:HEIDENREICH, JEANETTE LYNN, HOLLAND (COTA)
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:LYNN, HOLLAND
Last Name:HEIDENREICH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 PROVIDENT DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3252
Mailing Address - Country:US
Mailing Address - Phone:574-371-2500
Mailing Address - Fax:
Practice Address - Street 1:900 PROVIDENT DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3252
Practice Address - Country:US
Practice Address - Phone:574-371-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001369A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant