Provider Demographics
NPI:1457904237
Name:WHEELER, JENNIFER (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 AQUATIC DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3835
Mailing Address - Country:US
Mailing Address - Phone:904-707-0311
Mailing Address - Fax:
Practice Address - Street 1:3505 WATERCHASE WAY E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0802
Practice Address - Country:US
Practice Address - Phone:904-707-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11952224Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant