Healthcare Provider Details

I. General information

NPI: 1992454128
Provider Name (Legal Business Name): JESSICA PROVOST OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10095 BRICK CHURCH RD
CAMBRIDGE OH
43725-8550
US

IV. Provider business mailing address

2441 OHIO AVE
CAMBRIDGE OH
43725-9122
US

V. Phone/Fax

Practice location:
  • Phone: 740-439-8977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: