Provider Demographics
NPI:1790917367
Name:BETANCOURT, JENNIFER BAUCHMANN (OTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BAUCHMANN
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12009-5326
Mailing Address - Country:US
Mailing Address - Phone:518-861-3601
Mailing Address - Fax:
Practice Address - Street 1:140 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:NY
Practice Address - Zip Code:12009-5326
Practice Address - Country:US
Practice Address - Phone:518-861-3601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
NY007349-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant