Provider Demographics
NPI:1659420131
Name:JENNINGS, ELIZABETH (OTR)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 DONNIE AVE
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-8918
Mailing Address - Country:US
Mailing Address - Phone:254-634-8505
Mailing Address - Fax:254-781-4312
Practice Address - Street 1:1102 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542
Practice Address - Country:US
Practice Address - Phone:254-634-8505
Practice Address - Fax:254-519-3477
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110264225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161316801Medicaid