Provider Demographics
NPI:1720332323
Name:MANDEVILLE, JENNIFER ANN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:MANDEVILLE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DEER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-2326
Mailing Address - Country:US
Mailing Address - Phone:860-917-0499
Mailing Address - Fax:
Practice Address - Street 1:14 DEER RIDGE RD
Practice Address - Street 2:
Practice Address - City:KILLINGWORTH
Practice Address - State:CT
Practice Address - Zip Code:06419-2326
Practice Address - Country:US
Practice Address - Phone:860-917-0499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-04
Last Update Date:2012-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist