Provider Demographics
NPI:1104363191
Name:O'CONNOR, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:O'CONNOR
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 1:135 GROTKE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10977-7202
Mailing Address - Country:US
Mailing Address - Phone:845-422-0386
Mailing Address - Fax:
Practice Address - Street 1:135 GROTKE RD
Practice Address - Street 2:
Practice Address - City:CHESTNUT RIDGE
Practice Address - State:NY
Practice Address - Zip Code:10977-7202
Practice Address - Country:US
Practice Address - Phone:845-422-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009198-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant