Provider Demographics
NPI:1841243938
Name:BERTHELOT, JENNIFER SMITH (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SMITH
Last Name:BERTHELOT
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 1:7523 HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:ADDIS
Mailing Address - State:LA
Mailing Address - Zip Code:70710-2148
Mailing Address - Country:US
Mailing Address - Phone:225-687-0602
Mailing Address - Fax:225-687-0610
Practice Address - Street 1:7523 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ADDIS
Practice Address - State:LA
Practice Address - Zip Code:70710-2148
Practice Address - Country:US
Practice Address - Phone:225-687-0602
Practice Address - Fax:225-687-0610
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12039225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B589CM98Medicare ID - Type Unspecified