Provider Demographics
NPI:1174069249
Name:CARLSEN, JENNIFER (OTA, CKTP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:CARLSEN
Suffix:
Gender:F
Credentials:OTA, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4647 JUTLAND DR
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078-9507
Mailing Address - Country:US
Mailing Address - Phone:315-751-4647
Mailing Address - Fax:
Practice Address - Street 1:171 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2548
Practice Address - Country:US
Practice Address - Phone:315-437-4689
Practice Address - Fax:315-437-4698
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant