Provider Demographics
NPI:1285003764
Name:WANNALL, JEAN MARIE (OTR/L, OTD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:MARIE
Last Name:WANNALL
Suffix:
Gender:F
Credentials:OTR/L, OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 CLARK STREET EXT
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:NY
Mailing Address - Zip Code:13073-9401
Mailing Address - Country:US
Mailing Address - Phone:607-898-4282
Mailing Address - Fax:
Practice Address - Street 1:205 CLARK STREET EXT
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:NY
Practice Address - Zip Code:13073-9401
Practice Address - Country:US
Practice Address - Phone:607-898-4282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006296225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist