Healthcare Provider Details

I. General information

NPI: 1124719513
Provider Name (Legal Business Name): JESSICA SISA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 LATHAM DR
WARNER ROBINS GA
31088-2146
US

IV. Provider business mailing address

PO BOX 428
BONAIRE GA
31005-0428
US

V. Phone/Fax

Practice location:
  • Phone: 478-887-3141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT007135
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: