=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922844398
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIE ROSE BURDETTE OTD, OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2024
-----------------------------------------------------
Last Update Date | 07/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3025 SCIENCE PARK DR
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-7333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-455-6400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10085 CHEYENNE TRL APT 104
-----------------------------------------------------
City | PARMA HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44130-9097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | OT012926
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------