Healthcare Provider Details

I. General information

NPI: 1063533305
Provider Name (Legal Business Name): GARY LEE JENNINGS OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9743 MYRTLE CREEK LN
ORLANDO FL
32832-5909
US

IV. Provider business mailing address

9743 MYRTLE CREEK LN
ORLANDO FL
32832-5909
US

V. Phone/Fax

Practice location:
  • Phone: 407-482-6965
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number104437
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3996
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: