Provider Demographics
NPI:1457695876
Name:VANDENBURG, JENNIFER (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:VANDENBURG
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 OVERLOOK CIR
Mailing Address - Street 2:
Mailing Address - City:EUHARLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30145-2884
Mailing Address - Country:US
Mailing Address - Phone:678-463-2810
Mailing Address - Fax:
Practice Address - Street 1:78 OPAL ST
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2848
Practice Address - Country:US
Practice Address - Phone:770-382-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000964224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant