Provider Demographics
NPI:1629151378
Name:STICHT, JENNIFER LEE (OTR)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:STICHT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:BOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:3235 PCR 438
Mailing Address - Street 2:
Mailing Address - City:FROHNA
Mailing Address - State:MO
Mailing Address - Zip Code:63748-8176
Mailing Address - Country:US
Mailing Address - Phone:573-517-1715
Mailing Address - Fax:
Practice Address - Street 1:300 FLOYD DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-3960
Practice Address - Country:US
Practice Address - Phone:573-472-0397
Practice Address - Fax:573-472-0409
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004022321225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist