Provider Demographics
NPI:1851693386
Name:LI, JEN J (OTR)
Entity Type:Individual
Prefix:
First Name:JEN
Middle Name:J
Last Name:LI
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11802 BRINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1089
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4019 MAMARONECK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4742
Practice Address - Country:US
Practice Address - Phone:631-681-7288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-05
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY168485225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY168485OtherKENTUCKY BOARD OF LICENSURE FOR OCCUPATIONAL THERAPY