MEDICARE: MRS. JESSICA B EASTMAN MS, OTR/L

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
1	225X00000X	Occupational Therapist	642	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	315436	OTHER		BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1801061791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA B EASTMAN MS, OTR/L

Provider Business Mailing Address
First Line	:	PO BOX 12438
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83002-2438
Country	:	US
Telephone Number	:	307-413-8580
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 E BROADWAY AVE STE 8
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8636
Country	:	US
Telephone Number	:	307-413-8580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	03/13/2019

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