Provider Demographics
NPI:1922396795
Name:GFALL, JENNIFER LYNN (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:GFALL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 WINDING TRAIL RD.
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017
Mailing Address - Country:US
Mailing Address - Phone:810-240-5121
Mailing Address - Fax:
Practice Address - Street 1:1445 N 4TH ST
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1063
Practice Address - Country:US
Practice Address - Phone:715-246-8297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4832-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant