MEDICARE: MS. JESSICA ANNE HERBST OTA

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	224Z00000X	Occupational Therapy Assistant	002844-1	NY

General Provider Information

NPI Number	:	1881967933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA ANNE HERBST OTA

Provider Business Mailing Address
First Line	:	2 BROOKLYN HEIGHTS RD
Second Line	:	APT 1
City	:	MILAN
State	:	NY
Zip	:	12571-4706
Country	:	US
Telephone Number	:	845-656-8740
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 BROOKLYN HEIGHTS RD
Second Line	:	APT 1
City	:	MILAN
State	:	NY
Zip	:	12571-4706
Country	:	US
Telephone Number	:	845-656-8740
Fax Number	:

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

Provider Enumeration Date	:	02/21/2012
Last Update Date	:	02/21/2012

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