Provider Demographics
NPI:1790218204
Name:BANNON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 HIGHWAY A1A
Mailing Address - Street 2:SUITE 203
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3566
Mailing Address - Country:US
Mailing Address - Phone:321-773-8989
Mailing Address - Fax:
Practice Address - Street 1:2040 HIGHWAY A1A
Practice Address - Street 2:SUITE 203
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-3566
Practice Address - Country:US
Practice Address - Phone:321-773-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 15510224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant