Provider Demographics
NPI:1609193051
Name:SAMUEL, JENNIE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 DEWITT LOOP
Mailing Address - Street 2:FORT BELVOIR COMMUNITY HOSPITAL
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060
Mailing Address - Country:US
Mailing Address - Phone:571-231-1211
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:FORT BELVOIR COMMUNITY HOSPITAL
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060
Practice Address - Country:US
Practice Address - Phone:571-231-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06487225XM0800X, 225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation