Provider Demographics
NPI:1265772974
Name:JOHNSON, JENNIFER CLARK (OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CLARK
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 NW HALEAKALA WAY
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6726
Mailing Address - Country:US
Mailing Address - Phone:541-604-0548
Mailing Address - Fax:
Practice Address - Street 1:408 NE HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4729
Practice Address - Country:US
Practice Address - Phone:541-604-0548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1002972225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics