Provider Demographics
NPI:1740215227
Name:MCMENAMY, JEFFREY L (OTR)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:MCMENAMY
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3342
Mailing Address - Country:US
Mailing Address - Phone:307-857-7074
Mailing Address - Fax:307-856-6459
Practice Address - Street 1:820 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3342
Practice Address - Country:US
Practice Address - Phone:307-857-7074
Practice Address - Fax:307-856-6459
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR - 301225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121772100Medicaid
WYW9103Medicare UPIN