Provider Demographics
NPI:1962635292
Name:UNDERWOOD, JEFFERY SHAWN (OTR)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:SHAWN
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 AARON ST APT 111
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5309
Mailing Address - Country:US
Mailing Address - Phone:941-255-9468
Mailing Address - Fax:941-255-9506
Practice Address - Street 1:2305 AARON ST APT 111
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5309
Practice Address - Country:US
Practice Address - Phone:941-255-9468
Practice Address - Fax:941-255-9506
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10549225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist