=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265825400
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA T MAXWELL PHD, OTD, OTR, CEAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2015
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 348 GOODFELLA AVE STE 240
-----------------------------------------------------
City | CIBOLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78108-0198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-907-7768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 348 GOODFELLA AVE
-----------------------------------------------------
City | CIBOLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78108-0198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-907-7768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XE1200X
-----------------------------------------------------
Taxonomy Name | Ergonomics Occupational Therapist
-----------------------------------------------------
License Number | 122789
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 122789
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------