Provider Demographics
NPI:1689929614
Name:THACKER, JENNA L (OT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:L
Last Name:THACKER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:L
Other - Last Name:BETULIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:225 CROSSLAKE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8198
Practice Address - Country:US
Practice Address - Phone:812-471-6677
Practice Address - Fax:812-474-2296
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005322A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201107090Medicaid
IN000000782655OtherBLUE CROSS BLUE SHIELD
IN000000782963OtherBLUE CROSS BLUE SHIELD
IN000000783241OtherBLUE SHIELD BLUE CROSS
IN000000782655OtherBLUE CROSS BLUE SHIELD
IN216070001Medicare UPIN
IN201107090Medicaid