Provider Demographics
NPI:1043554405
Name:GUSTAFSON, JENNIFER HELEN (OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HELEN
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:HELEN
Other - Last Name:OLIVERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:45 PORTLAND RD STE 71037
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6660
Mailing Address - Country:US
Mailing Address - Phone:207-358-9422
Mailing Address - Fax:
Practice Address - Street 1:45 PORTLAND RD STE 71037
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6660
Practice Address - Country:US
Practice Address - Phone:207-358-9422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-24
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2570225X00000X, 225X00000X
225XP0200X, 225XP0200X
MA10511225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics