Provider Demographics
NPI:1093040834
Name:AGNEW, JESSICA KATHLEEN (OT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:KATHLEEN
Last Name:AGNEW
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:KATHLEEN
Other - Last Name:GRABO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:314 S MANNING BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1708
Mailing Address - Country:US
Mailing Address - Phone:518-577-6106
Mailing Address - Fax:
Practice Address - Street 1:314 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1708
Practice Address - Country:US
Practice Address - Phone:518-577-6106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015481-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist