Provider Demographics
NPI:1861043572
Name:EDMISTER, JENNIFER DIANE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:EDMISTER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 1ST AVE S STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4364
Mailing Address - Country:US
Mailing Address - Phone:727-803-1102
Mailing Address - Fax:727-502-6027
Practice Address - Street 1:1320 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4860
Practice Address - Country:US
Practice Address - Phone:727-803-1102
Practice Address - Fax:727-502-6027
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10795225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist