Provider Demographics
NPI:1902380421
Name:MEIDENBAUER, JILLIAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:MEIDENBAUER
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 1:4902 CREEKSIDE DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-4033
Mailing Address - Country:US
Mailing Address - Phone:727-592-9100
Mailing Address - Fax:
Practice Address - Street 1:4902 CREEKSIDE DR STE A
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-4033
Practice Address - Country:US
Practice Address - Phone:727-592-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19452225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty