Provider Demographics
NPI:1427454792
Name:POWELSON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:POWELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:POWELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:18126 LINCOLN HWY E
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46773-9788
Mailing Address - Country:US
Mailing Address - Phone:260-348-0632
Mailing Address - Fax:
Practice Address - Street 1:10445 DUPONT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8792
Practice Address - Country:US
Practice Address - Phone:260-471-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001187A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant