Provider Demographics
NPI:1780938738
Name:BUEBY, JENNIFER NICOLE (OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:BUEBY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:JASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7468 DRY CREEK DR APT 3A
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-6316
Mailing Address - Country:US
Mailing Address - Phone:810-730-6362
Mailing Address - Fax:
Practice Address - Street 1:7005 PONTIAC TRAIL
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2181
Practice Address - Country:US
Practice Address - Phone:810-730-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008327225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist