Healthcare Provider Details

I. General information

NPI: 1922146919
Provider Name (Legal Business Name): JENNIFER SKIDMORE OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1689 EAGLE HARBOR PKWY SUITE D
ORANGE PARK FL
32003-4802
US

IV. Provider business mailing address

970 SWEETWOOD CT
ORANGE PARK FL
32065-8943
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-0148
  • Fax: 904-637-0155
Mailing address:
  • Phone: 904-213-0822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number11909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: