Healthcare Provider Details

I. General information

NPI: 1790114551
Provider Name (Legal Business Name): JENNIFER KUDLO MS OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 11/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3057 GULL RD
KALAMAZOO MI
49048-1281
US

IV. Provider business mailing address

3057 GULL RD
KALAMAZOO MI
49048-1281
US

V. Phone/Fax

Practice location:
  • Phone: 269-552-6521
  • Fax:
Mailing address:
  • Phone: 269-552-6521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201006337
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: