Healthcare Provider Details

I. General information

NPI: 1669614905
Provider Name (Legal Business Name): KATHLEEN LEONTINE JESSEN OTR/L, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11309 DUSTY TRAIL CT
ROANOKE TX
76262-1927
US

IV. Provider business mailing address

PO BOX 1192
ARGYLE TX
76226-1192
US

V. Phone/Fax

Practice location:
  • Phone: 940-208-9198
  • Fax:
Mailing address:
  • Phone: 940-208-9198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL302117
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number122278
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number122278
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number122278
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: