Provider Demographics
NPI:1285499210
Name:GRACE, JENNIFER DARLENE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DARLENE
Last Name:GRACE
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 1:305 RIPLEY 160E-13
Mailing Address - Street 2:
Mailing Address - City:FAIRDEALING
Mailing Address - State:MO
Mailing Address - Zip Code:63939-8051
Mailing Address - Country:US
Mailing Address - Phone:573-382-6828
Mailing Address - Fax:
Practice Address - Street 1:305 RIPLEY 160E-13
Practice Address - Street 2:
Practice Address - City:FAIRDEALING
Practice Address - State:MO
Practice Address - Zip Code:63939-8051
Practice Address - Country:US
Practice Address - Phone:573-382-6828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification