Provider Demographics
NPI:1689703621
Name:LOCKARD, JENNIFER RENE (OT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RENE
Last Name:LOCKARD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501
Mailing Address - Country:US
Mailing Address - Phone:606-677-1166
Mailing Address - Fax:606-677-0693
Practice Address - Street 1:129 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501
Practice Address - Country:US
Practice Address - Phone:606-677-1166
Practice Address - Fax:606-677-0693
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR-3259225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1783OtherCBIS BILLING PROVIDER ID