=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568185049
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ROSELLA CROWSON MOT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14701 E 86TH ST N
-----------------------------------------------------
City | OWASSO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74055-8474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-205-4790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9585 E 350 RD
-----------------------------------------------------
City | TALALA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74080-9511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-724-9096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 5371
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------