Healthcare Provider Details

I. General information

NPI: 1336289750
Provider Name (Legal Business Name): JENNIFER BAYRON OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BURNS AVE
LAKE WALES FL
33853-3335
US

IV. Provider business mailing address

2403 E HENRY AVE
TAMPA FL
33610-4434
US

V. Phone/Fax

Practice location:
  • Phone: 863-679-3338
  • Fax:
Mailing address:
  • Phone: 813-988-7633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT5188
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: