Provider Demographics
NPI:1487047080
Name:DORTCH, STEPHANIE JENAE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JENAE
Last Name:DORTCH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:JENAE
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:5155 KAYWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4609
Mailing Address - Country:US
Mailing Address - Phone:601-594-8242
Mailing Address - Fax:
Practice Address - Street 1:809 WINDLASS CV
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7035
Practice Address - Country:US
Practice Address - Phone:601-720-7206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2010224Z00000X
MSOT3608225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant