Healthcare Provider Details

I. General information

NPI: 1114440989
Provider Name (Legal Business Name): JENNI SHANE HERMAN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 E 17TH ST
BROOKLYN NY
11229-1259
US

IV. Provider business mailing address

1663 E 17TH ST
BROOKLYN NY
11229-1259
US

V. Phone/Fax

Practice location:
  • Phone: 718-998-0200
  • Fax:
Mailing address:
  • Phone: 718-998-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number021418
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: