Provider Demographics
NPI:1336161553
Name:VELLIQUETTE, JENNIFER L (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:VELLIQUETTE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:VELLIQUETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:818 MOORINGS DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9451
Mailing Address - Country:US
Mailing Address - Phone:814-441-5333
Mailing Address - Fax:
Practice Address - Street 1:3662 POINSETTIA AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5546
Practice Address - Country:US
Practice Address - Phone:616-243-0305
Practice Address - Fax:616-243-0305
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007844225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201007844OtherSTATE LICENSE