Provider Demographics
NPI:1306090162
Name:SOUTHWELL, JENNIFER (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17821 NW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3061
Mailing Address - Country:US
Mailing Address - Phone:954-436-4845
Mailing Address - Fax:305-591-5691
Practice Address - Street 1:17821 NW 19TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3061
Practice Address - Country:US
Practice Address - Phone:954-436-4845
Practice Address - Fax:305-591-5691
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10348225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist