Provider Demographics
NPI:1841769833
Name:WILDEROTTER, JEANNE (LOTR)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:WILDEROTTER
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:B
Other - Last Name:DUPUY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8300 EARHART BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-4428
Mailing Address - Country:US
Mailing Address - Phone:504-866-6990
Mailing Address - Fax:504-866-6991
Practice Address - Street 1:8300 EARHART BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-4428
Practice Address - Country:US
Practice Address - Phone:504-866-6990
Practice Address - Fax:504-866-6991
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA308746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist