Provider Demographics
NPI:1033488176
Name:ROMERO, JESSICA JANE (COTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JANE
Last Name:ROMERO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 GRIMES AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3217
Mailing Address - Country:US
Mailing Address - Phone:763-450-2737
Mailing Address - Fax:
Practice Address - Street 1:3130 GRIMES AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-3217
Practice Address - Country:US
Practice Address - Phone:763-450-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201610224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant