Provider Demographics
NPI:1790754943
Name:ANDERSON, JENIFER A (MS,OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JENIFER
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 INDIAN TRAIL RD S STE 141
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-8689
Mailing Address - Country:US
Mailing Address - Phone:704-975-7008
Mailing Address - Fax:704-821-0750
Practice Address - Street 1:598 INDIAN TRAIL RD S STE 141
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-8689
Practice Address - Country:US
Practice Address - Phone:704-975-7008
Practice Address - Fax:704-821-0750
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5635225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0103COtherBCBS
NC7301861Medicaid
NC64-42619OtherUHC