Healthcare Provider Details

I. General information

NPI: 1790754943
Provider Name (Legal Business Name): JENIFER A ANDERSON MS,OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

598 INDIAN TRAIL RD S STE 141
INDIAN TRAIL NC
28079-8689
US

IV. Provider business mailing address

598 INDIAN TRAIL RD S STE 141
INDIAN TRAIL NC
28079-8689
US

V. Phone/Fax

Practice location:
  • Phone: 704-975-7008
  • Fax: 704-821-0750
Mailing address:
  • Phone: 704-975-7008
  • Fax: 704-821-0750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5635
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: