Healthcare Provider Details

I. General information

NPI: 1609379718
Provider Name (Legal Business Name): JEREMY ETISOMBA OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11440 ROSE LN
CINCINNATI OH
45246-2922
US

IV. Provider business mailing address

11440 ROSE LN
CINCINNATI OH
45246-2922
US

V. Phone/Fax

Practice location:
  • Phone: 513-667-6033
  • Fax:
Mailing address:
  • Phone: 513-667-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT010001
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: