Provider Demographics
NPI:1588867329
Name:MARK, JENNY S (OT)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:S
Last Name:MARK
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 1:4555 DAWSON RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45333-9635
Mailing Address - Country:US
Mailing Address - Phone:937-498-1863
Mailing Address - Fax:
Practice Address - Street 1:253 W SIXTH ST
Practice Address - Street 2:
Practice Address - City:MINSTER
Practice Address - State:OH
Practice Address - Zip Code:45865
Practice Address - Country:US
Practice Address - Phone:419-501-2165
Practice Address - Fax:419-501-2166
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT006719225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH232804807OtherREHAB PROVIDER NETWORK
OH1575832OtherFIRST HEALTH/COVENTRY
OH000000523169OtherBLUE CROSS BLUE SHIELD
OH2781431Medicaid
OH2781431Medicaid
OH$$$$$$$$$001OtherMEDICAL MUTUAL
OHMA4215241Medicare PIN