Healthcare Provider Details

I. General information

NPI: 1588840086
Provider Name (Legal Business Name): JENNIFER KERTYZAK MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 NORWOOD AVE
CRANSTON RI
02905-3923
US

IV. Provider business mailing address

178 NORWOOD AVE
CRANSTON RI
02905-3923
US

V. Phone/Fax

Practice location:
  • Phone: 401-921-1470
  • Fax:
Mailing address:
  • Phone: 401-474-2486
  • Fax: 617-383-6520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number9067
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: