Healthcare Provider Details

I. General information

NPI: 1912383035
Provider Name (Legal Business Name): ALLYSON JELENEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S CONGRESS ST
YORK SC
29745-1836
US

IV. Provider business mailing address

15 DENISON ST
NEWARK DE
19711-4359
US

V. Phone/Fax

Practice location:
  • Phone: 803-684-0035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number07615
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number.4525
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: