Provider Demographics
NPI:1124841622
Name:HEROLD, JENNIFER (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HEROLD
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 1:3 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-2632
Mailing Address - Country:US
Mailing Address - Phone:440-479-4308
Mailing Address - Fax:
Practice Address - Street 1:3 LAUREL LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-2632
Practice Address - Country:US
Practice Address - Phone:440-479-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7593225X00000X
GA006805225X00000X
IN31006948A225X00000X
MI5201010301225X00000X
SC4354225X00000X
TN6315225X00000X
WA60881087225X00000X
FL20139225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist