Provider Demographics
NPI:1649463852
Name:AMBUSH, JENNILEE O (OT)
Entity type:Individual
Prefix:
First Name:JENNILEE
Middle Name:O
Last Name:AMBUSH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNILEE
Other - Middle Name:
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:86 THOMAS JOHNSON CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4348
Mailing Address - Country:US
Mailing Address - Phone:301-694-8311
Mailing Address - Fax:301-694-3537
Practice Address - Street 1:86 THOMAS JOHNSON CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4348
Practice Address - Country:US
Practice Address - Phone:301-694-8311
Practice Address - Fax:301-694-3537
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05916225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist