Basic Information
| Provider Information | |||||||||
| NPI: | 1649813593 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347485138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898827305 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 S. MARION AVE | ||||||||
| Address2: | PM & RS OT | ||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2019 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA16231 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.