Healthcare Provider Details

I. General information

NPI: 1851112510
Provider Name (Legal Business Name): JASMINE MAE HICKEY MOT, BSN, OTR/L, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 YOUNGSTOWN WARREN RD
NILES OH
44446-4624
US

IV. Provider business mailing address

1669 HOUSEL CRAFT RD
BRISTOLVILLE OH
44402-9602
US

V. Phone/Fax

Practice location:
  • Phone: 330-505-2800
  • Fax:
Mailing address:
  • Phone: 330-240-4785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN.494791
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT013078
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: