Provider Demographics
NPI:1962647123
Name:CROOM, JENNIFER C (OTR)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:CROOM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5690 SANTA TERESITA DR
Mailing Address - Street 2:STE A-1
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9206
Mailing Address - Country:US
Mailing Address - Phone:915-342-3399
Mailing Address - Fax:866-830-3399
Practice Address - Street 1:5690 SANTA TERESITA DR
Practice Address - Street 2:STE A-1
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9206
Practice Address - Country:US
Practice Address - Phone:915-342-3399
Practice Address - Fax:866-830-3399
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1426225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist