Provider Demographics
NPI:1922421460
Name:RIDEOUT, JENNILEE LEBLANC
Entity Type:Individual
Prefix:
First Name:JENNILEE
Middle Name:LEBLANC
Last Name:RIDEOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNILEE
Other - Middle Name:
Other - Last Name:LEBLANC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1801 TURNPIKE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-6322
Mailing Address - Country:US
Mailing Address - Phone:781-632-1082
Mailing Address - Fax:
Practice Address - Street 1:1801 TURNPIKE ST
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-6322
Practice Address - Country:US
Practice Address - Phone:781-632-1082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3474224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant