=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093538639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA JILL MCDERMOTT OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 S WALNUT AVE
-----------------------------------------------------
City | COOKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38501-5956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-528-5516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 NUNALLY DR
-----------------------------------------------------
City | BAXTER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38544-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-854-5936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 4743
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------