Provider Demographics
NPI:1104988260
Name:UTTERBACK, JENNIFER LYNN
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:FOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:719 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-3035
Mailing Address - Country:US
Mailing Address - Phone:217-440-4566
Mailing Address - Fax:
Practice Address - Street 1:6000 HOSPITAL DRIVE
Practice Address - Street 2:HANNIBAL REGIONAL HOSPITAL
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401
Practice Address - Country:US
Practice Address - Phone:573-248-5346
Practice Address - Fax:573-248-5364
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002018271225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics