=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578016986
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA SCHACKER OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2016
-----------------------------------------------------
Last Update Date | 08/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 227 COLUMBUS AVE APT 1A
-----------------------------------------------------
City | PORT CHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10573-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-603-8568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 227 COLUMBUS AVE APT 1A
-----------------------------------------------------
City | PORT CHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10573-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-603-8568
-----------------------------------------------------
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 | 020525-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------