Provider Demographics
NPI:1760508477
Name:ANDERSON, JENNIFER (OTRL)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:475 HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1707
Mailing Address - Country:US
Mailing Address - Phone:860-536-6070
Mailing Address - Fax:860-536-9480
Practice Address - Street 1:475 HIGH STREET
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1707
Practice Address - Country:US
Practice Address - Phone:860-536-6070
Practice Address - Fax:860-536-9480
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00338224Z00000X
CT005123225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant