=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114370020
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER MICHELLE FINE BS, MOT R//L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2016
-----------------------------------------------------
Last Update Date | 01/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 LINDSEY LN
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-510-6104
-----------------------------------------------------
Fax | 912-882-6137
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 LINDSEY LN
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558-1635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-510-6104
-----------------------------------------------------
Fax | 912-882-6137
-----------------------------------------------------
=====================================================
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 | OC013633
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT007252
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------