Provider Demographics
NPI:1003825050
Name:SANG, JESSICA (OT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:SANG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12899 E 76TH ST N
Mailing Address - Street 2:109
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12899 E 76TH ST N
Practice Address - Street 2:109
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4021
Practice Address - Country:US
Practice Address - Phone:918-609-6003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK944225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100645670AMedicaid