Provider Demographics
NPI:1891955290
Name:CRAIG, JENENE KAE (MBA, OTR/L)
Entity Type:Individual
Prefix:
First Name:JENENE
Middle Name:KAE
Last Name:CRAIG
Suffix:
Gender:F
Credentials:MBA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 GROVE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5613
Mailing Address - Country:US
Mailing Address - Phone:770-595-7728
Mailing Address - Fax:770-277-7976
Practice Address - Street 1:415 GROVE RIDGE DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5613
Practice Address - Country:US
Practice Address - Phone:770-595-7728
Practice Address - Fax:770-277-7976
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000486225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist