Healthcare Provider Details

I. General information

NPI: 1568199750
Provider Name (Legal Business Name): JAI WAYNE ESCHETE OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2022
Last Update Date: 08/07/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 HIGH FOREST LN
TUPELO MS
38801-7800
US

IV. Provider business mailing address

108 HIGH FOREST LN
TUPELO MS
38801-7800
US

V. Phone/Fax

Practice location:
  • Phone: 662-322-3077
  • Fax:
Mailing address:
  • Phone: 662-322-3077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT1452
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: