Provider Demographics
NPI:1881146322
Name:DAVIS, JENNIE
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 WOODROW AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-1140
Mailing Address - Country:US
Mailing Address - Phone:888-265-2680
Mailing Address - Fax:
Practice Address - Street 1:5535 S WILLIAMSON BLVD
Practice Address - Street 2:STE. 774
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8311
Practice Address - Country:US
Practice Address - Phone:888-265-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT008257225X00000X
SC4509225X00000X
WV1821225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist