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NPI Code Detail

MEDICARE: JESSICA LEE DAUGHERTY-PETERS OTRL

MEDICARE: JESSICA LEE DAUGHERTY-PETERS OTRL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225X00000XOccupational TherapistR3595KY

General Provider Information

NPI Number : 1255425161
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSICA LEE DAUGHERTY-PETERS OTRL
Provider Business Mailing Address
First Line : PO BOX 86
Second Line :
City : SANDGAP
State : KY
Zip : 40481-0086
Country : US
Telephone Number : 859-779-8507
Fax Number :
Provider Business Practice Location Address
First Line : 1043 BROOKLYN BLVD
Second Line :
City : BEREA
State : KY
Zip : 40403-1090
Country : US
Telephone Number : 859-779-8507
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/03/2006
Last Update Date : 07/15/2020

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