Provider Demographics
NPI:1245369230
Name:OLTERSDORF, JENNIFER M (COTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:OLTERSDORF
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 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:610-991-2034
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:14560 LAKESIDE CIR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1350
Practice Address - Country:US
Practice Address - Phone:610-991-2034
Practice Address - Fax:610-438-2046
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP00930Medicare ID - Type UnspecifiedPART B GROUP NUMBER