Provider Demographics
NPI:1942329958
Name:FOUNTAIN, JEANIE DEE (OTR)
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:DEE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5145 FILLMORE CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-3671
Mailing Address - Country:US
Mailing Address - Phone:563-543-4525
Mailing Address - Fax:
Practice Address - Street 1:2730 CROW CREEK RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-2066
Practice Address - Country:US
Practice Address - Phone:563-543-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01203225X00000X
KS998225X00000X
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist