Provider Demographics
NPI:1720643547
Name:O'LEARY, JENNIFER LYNN (OTRL)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 SHELL DR APT 120
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-2068
Mailing Address - Country:US
Mailing Address - Phone:269-615-5083
Mailing Address - Fax:
Practice Address - Street 1:103 SLEEPY DR STE G
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3319
Practice Address - Country:US
Practice Address - Phone:910-587-6065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12504225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist