Basic Information
| Provider Information | |||||||||
| NPI: | 1689929614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THACKER | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BETULIUS | ||||||||
| OtherFirstName: | JENNA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7300 E INDIANA ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477152794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124760409 | ||||||||
| FaxNumber: | 8124761016 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CROSSLAKE DR | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477158198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124716677 | ||||||||
| FaxNumber: | 8124742296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2012 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31005322A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 201107090 | 05 | IN | MEDICAID | 000000782655 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 000000782963 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 000000783241 | 01 | IN | BLUE SHIELD BLUE CROSS | OTHER |