Provider Demographics
NPI:1619214335
Name:GARDENER, JENNILLE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JENNILLE
Middle Name:
Last Name:GARDENER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E 88TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-1242
Mailing Address - Country:US
Mailing Address - Phone:718-644-3809
Mailing Address - Fax:
Practice Address - Street 1:116 E 88TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-1242
Practice Address - Country:US
Practice Address - Phone:718-644-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63016335225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist