Healthcare Provider Details

I. General information

NPI: 1073945911
Provider Name (Legal Business Name): JESSICA OTIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 BARONNE ST
NEW ORLEANS LA
70115-4705
US

IV. Provider business mailing address

4105 BARONNE ST
NEW ORLEANS LA
70115-4705
US

V. Phone/Fax

Practice location:
  • Phone: 504-237-7585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: