Healthcare Provider Details

I. General information

NPI: 1689929614
Provider Name (Legal Business Name): JENNA L THACKER OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA L BETULIUS OT

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CROSSLAKE DR
EVANSVILLE IN
47715-8198
US

IV. Provider business mailing address

7300 E INDIANA ST SUITE 102
EVANSVILLE IN
47715-2794
US

V. Phone/Fax

Practice location:
  • Phone: 812-471-6677
  • Fax: 812-474-2296
Mailing address:
  • Phone: 812-476-0409
  • Fax: 812-476-1016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31005322A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: