MEDICARE: JESSICA LEA OTT PTA

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	225200000X	Physical Therapy Assistant	13212	CO
2	225200000X	Physical Therapy Assistant	A5092	NC

General Provider Information

NPI Number	:	1801224357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LEA OTT PTA

Provider Business Mailing Address
First Line	:	1067 S HOVER ST STE E
Second Line	:	PMB 187
City	:	LONGMONT
State	:	CO
Zip	:	80501-7903
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1067 S HOVER ST STE E
Second Line	:	PMB 187
City	:	LONGMONT
State	:	CO
Zip	:	80501-7903
Country	:	US
Telephone Number	:	828-275-7114
Fax Number	:

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

Provider Enumeration Date	:	10/21/2013
Last Update Date	:	02/04/2014

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