Healthcare Provider Details

I. General information

NPI: 1164723425
Provider Name (Legal Business Name): JESSICA NICOLE DAVIS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 WALTER MARTIN RD NE
FORT WALTON BEACH FL
32548-4960
US

IV. Provider business mailing address

2505 GEORGETOWN LN
FORT WALTON BEACH FL
32547-6818
US

V. Phone/Fax

Practice location:
  • Phone: 850-862-7227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT14375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: