Provider Demographics
NPI:1760878169
Name:MAYNARD, JESSIE (OT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:BOHLANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:7901 E 88TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1235
Mailing Address - Country:US
Mailing Address - Phone:317-849-5437
Mailing Address - Fax:
Practice Address - Street 1:7901 E 88TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1235
Practice Address - Country:US
Practice Address - Phone:317-849-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005850A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist