Provider Demographics
NPI:1003389693
Name:BLAIR, JESSICA (OCCUPATIONAL THERAPY)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REVERE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1774
Practice Address - Country:US
Practice Address - Phone:866-812-8896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008094224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant