Provider Demographics
NPI:1629153655
Name:BERTRAM, JENNIFER S (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:POLETE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-0369
Mailing Address - Country:US
Mailing Address - Phone:864-329-4211
Mailing Address - Fax:678-840-2112
Practice Address - Street 1:213 E BUTLER RD BLDG E2
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2172
Practice Address - Country:US
Practice Address - Phone:864-346-0391
Practice Address - Fax:678-840-2112
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2870225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1467Medicaid