Provider Demographics
NPI:1790107993
Name:DESLICH, JENNIFER (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DESLICH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4649 E WOLF CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TIGER
Mailing Address - State:GA
Mailing Address - Zip Code:30576-2946
Mailing Address - Country:US
Mailing Address - Phone:678-357-5849
Mailing Address - Fax:
Practice Address - Street 1:165 RIDGECREST CIR STE B
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-4196
Practice Address - Country:US
Practice Address - Phone:678-357-5849
Practice Address - Fax:706-534-6750
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15112225XF0002X, 225XP0200X
GAOT005828225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & Swallowing
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003141022AMedicaid