Basic Information
| Provider Information | |||||||||
| NPI: | 1528543097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20211 SUGARLOAF RESERVE DR | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300975216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703141113 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7035 SAINT ANDREWS RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292121177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037490924 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2018 | ||||||||
| 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 | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 5404 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.