Provider Demographics
NPI:1063859031
Name:MOSS, JESSICA DIANE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:DIANE
Last Name:MOSS
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 1:110 FORESTDALE DR
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29341-2625
Mailing Address - Country:US
Mailing Address - Phone:864-706-6729
Mailing Address - Fax:
Practice Address - Street 1:110 FORESTDALE DR
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2625
Practice Address - Country:US
Practice Address - Phone:864-706-6729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2993224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant