Provider Demographics
NPI:1770042459
Name:BOSWORTH, JENNIFER (ORTL)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:ORTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 DONNA DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1133
Practice Address - Country:US
Practice Address - Phone:800-321-9357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010497225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist