Healthcare Provider Details

I. General information

NPI: 1154770311
Provider Name (Legal Business Name): JESSICA RODGERS MOT, LOTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 WILLIE HILL RD
GILBERT LA
71336-5864
US

IV. Provider business mailing address

991 WILLIE HILL RD
GILBERT LA
71336-5864
US

V. Phone/Fax

Practice location:
  • Phone: 318-789-5332
  • Fax:
Mailing address:
  • Phone: 318-789-5332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA.200221
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: