Provider Demographics
NPI:1699940254
Name:LEAVITT, JENNIFER LINDE (MSOT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LINDE
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LINDE
Other - Last Name:LAYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 ELLIS POTTER CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2478
Mailing Address - Country:US
Mailing Address - Phone:608-204-6246
Mailing Address - Fax:
Practice Address - Street 1:14 ELLIS POTTER CT
Practice Address - Street 2:SUITE 200
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2478
Practice Address - Country:US
Practice Address - Phone:608-204-6246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4633-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist