Provider Demographics
NPI:1881032704
Name:MCLELLEN, JENNIFER (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCLELLEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 KENMOOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3641
Mailing Address - Country:US
Mailing Address - Phone:616-826-0855
Mailing Address - Fax:
Practice Address - Street 1:709 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1226
Practice Address - Country:US
Practice Address - Phone:269-792-4440
Practice Address - Fax:269-792-4475
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007338224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant