MEDICARE: MRS. JENNIFER LYNN BRIDGERS OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	OTR1433	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5W519	OTHER	AR	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1083700637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER LYNN BRIDGERS OTR/L

Provider Business Mailing Address
First Line	:	5355 PEWTER DRIVE
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-7640
Country	:	US
Telephone Number	:	501-733-5117
Fax Number	:

Provider Business Practice Location Address
First Line	:	5355 PEWTER DRIVE
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-7640
Country	:	US
Telephone Number	:	501-733-5117
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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