=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144386095
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER NINA MAVES OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2705 ENLOE ST
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-8173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-386-2128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 S PLUM ST
-----------------------------------------------------
City | ELLSWORTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54011-4137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-497-3277
-----------------------------------------------------
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 | 3526
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------