Healthcare Provider Details

I. General information

NPI: 1992384697
Provider Name (Legal Business Name): JESSICA MARCUS MSOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 W ROOSEVELT BLVD STE C
MONROE NC
28110-3788
US

IV. Provider business mailing address

1219 GRAMERCY DR
INDIAN TRAIL NC
28079-0377
US

V. Phone/Fax

Practice location:
  • Phone: 980-422-5588
  • Fax:
Mailing address:
  • Phone: 704-962-1061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number13912
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: