Healthcare Provider Details

I. General information

NPI: 1750510350
Provider Name (Legal Business Name): JESSICA SURFACE MS, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2009
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 ASHLEY RIVER RD
CHARLESTON SC
29407-5305
US

IV. Provider business mailing address

1407 ASHLEY RIVER RD
CHARLESTON SC
29407-5305
US

V. Phone/Fax

Practice location:
  • Phone: 843-769-0663
  • Fax: 843-769-0665
Mailing address:
  • Phone: 843-769-0663
  • Fax: 843-769-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number7273
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31004801A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number4130
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4130
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: