Provider Demographics
NPI:1548504095
Name:O'BRYAN, JEANINE MARY (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:MARY
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13502 ROCK BAY CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-2097
Mailing Address - Country:US
Mailing Address - Phone:502-241-4689
Mailing Address - Fax:
Practice Address - Street 1:1040 US HIGHWAY 127 S
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4326
Practice Address - Country:US
Practice Address - Phone:502-226-2064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-22
Last Update Date:2012-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA5298224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant