Healthcare Provider Details

I. General information

NPI: 1689792061
Provider Name (Legal Business Name): JENNIE ANN TANNER OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIE ANN KAY OT

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BUTTERCUP CREEK BLVD STE. 122
CEDAR PARK TX
78613-3708
US

IV. Provider business mailing address

2602 SILVER SPUR LN
LEANDER TX
78641-7885
US

V. Phone/Fax

Practice location:
  • Phone: 512-219-8890
  • Fax: 512-258-0090
Mailing address:
  • Phone: 512-535-2349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number112044
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: