Provider Demographics
NPI:1750581443
Name:NEEL, JENNY MUDD (MSOT, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:MUDD
Last Name:NEEL
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 TRINITY CEMETERY LOOP
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-7914
Mailing Address - Country:US
Mailing Address - Phone:502-348-5798
Mailing Address - Fax:
Practice Address - Street 1:704 BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2025
Practice Address - Country:US
Practice Address - Phone:502-331-5478
Practice Address - Fax:502-348-9825
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3653225X00000X
KY134493225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50116374OtherPASSPORT HEALTH
KY7100424370Medicaid
KY000001039542OtherANTHEM