Provider Demographics
NPI:1043972581
Name:PAULINE, JESSICA (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PAULINE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 GLOVER ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4627
Mailing Address - Country:US
Mailing Address - Phone:304-444-8573
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-2304
Practice Address - Country:US
Practice Address - Phone:304-768-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2392224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant