Healthcare Provider Details

I. General information

NPI: 1568793230
Provider Name (Legal Business Name): JENNIFER L BASTIAN MS, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11550 N MERIDIAN ST STE 312
CARMEL IN
46032-4562
US

IV. Provider business mailing address

3610 DRIFTWOOD DR S APT 100
LAFAYETTE IN
47905-6045
US

V. Phone/Fax

Practice location:
  • Phone: 317-815-0781
  • Fax:
Mailing address:
  • Phone: 317-439-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number31003827A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: