Provider Demographics
NPI:1821691874
Name:NICK, JENNIFER (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NICK
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 1:307 ROUNDABOUT DR
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-1289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 ROUNDABOUT DR
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-1289
Practice Address - Country:US
Practice Address - Phone:205-410-8752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2515225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics