Provider Demographics
NPI:1548642937
Name:KING, JENNIFER BOHNERT (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BOHNERT
Last Name:KING
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:BOHNERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 740041
Mailing Address - Street 2:DEPT 6150
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-7441
Mailing Address - Country:US
Mailing Address - Phone:502-561-4295
Mailing Address - Fax:502-562-0348
Practice Address - Street 1:225 ABRAHAM FLEXNER WAY STE 650
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1888
Practice Address - Country:US
Practice Address - Phone:502-561-4295
Practice Address - Fax:502-562-0348
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBOTOCT00219071225X00000X
IN31005877A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201306870Medicaid
KY7100349190Medicaid
IN233630005Medicare PIN
KYK152680Medicare PIN