Basic Information
| Provider Information | |||||||||
| NPI: | 1336289750 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAYRON | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2403 E HENRY AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336104434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139887633 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 BURNS AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338533335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636793338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT5188 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 89059106 | 05 | FL | MEDICAID |