MEDICARE: JENNA WOODSIDE MOT/R

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	225X00000X	Occupational Therapist	2010023598	MO

General Provider Information

NPI Number	:	1790560993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA WOODSIDE MOT/R

Provider Business Mailing Address
First Line	:	619 DOUGHERTY FERRY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-2512
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	619 DOUGHERTY FERRY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-2512
Country	:	US
Telephone Number	:	260-433-1811
Fax Number	:

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

Provider Enumeration Date	:	08/28/2023
Last Update Date	:	08/28/2023

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Directions to “ JENNA WOODSIDE MOT/R” Practice Location

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