Provider Demographics
NPI:1316112527
Name:JENNINGS-EAKIN, KEISHA (OT)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:JENNINGS-EAKIN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2962 COLCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-1922
Mailing Address - Country:US
Mailing Address - Phone:443-402-5490
Mailing Address - Fax:434-420-6747
Practice Address - Street 1:658 BOULTON ST
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4214
Practice Address - Country:US
Practice Address - Phone:301-581-8054
Practice Address - Fax:301-564-0284
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06121225X00000X, 225XE0001X, 225XG0600X, 225XR0403X
MDT00599225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD131611257Medicaid