Provider Demographics
NPI:1871161752
Name:BAIN, JENNIFER ANN (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BAIN
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 1:13241 12 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-9367
Mailing Address - Country:US
Mailing Address - Phone:616-428-2451
Mailing Address - Fax:
Practice Address - Street 1:615 S BOWER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2614
Practice Address - Country:US
Practice Address - Phone:616-428-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist