Provider Demographics
NPI:1629336466
Name:GOEDL, JENNY LEE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:JENNY
Middle Name:LEE
Last Name:GOEDL
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 1:1053 CHULA VISTA CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-2242
Mailing Address - Country:US
Mailing Address - Phone:317-698-9210
Mailing Address - Fax:
Practice Address - Street 1:1701 LIBRARY BLVD STE A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1567
Practice Address - Country:US
Practice Address - Phone:317-881-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002147A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist