Provider Demographics
NPI:1689792061
Name:TANNER, JENNIE ANN (OT)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:ANN
Last Name:TANNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:ANN
Other - Last Name:KAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:2602 SILVER SPUR LN
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-7885
Mailing Address - Country:US
Mailing Address - Phone:512-535-2349
Mailing Address - Fax:
Practice Address - Street 1:200 BUTTERCUP CREEK BLVD
Practice Address - Street 2:STE. 122
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3708
Practice Address - Country:US
Practice Address - Phone:512-219-8890
Practice Address - Fax:512-258-0090
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112044225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist