Provider Demographics
NPI:1588453708
Name:VICARS, SHENOAH JADE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:SHENOAH
Middle Name:JADE
Last Name:VICARS
Suffix:
Gender:
Credentials:OTR/L
Other - Prefix:
Other - First Name:SHENOAH
Other - Middle Name:JADE
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:100 OLD CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-7208
Mailing Address - Country:US
Mailing Address - Phone:423-480-7518
Mailing Address - Fax:
Practice Address - Street 1:2214 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2860
Practice Address - Country:US
Practice Address - Phone:423-928-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8289225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist