Provider Demographics
NPI:1093105314
Name:OTZ, JESSICA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OTZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 FIRST VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8724
Mailing Address - Country:US
Mailing Address - Phone:910-235-2713
Mailing Address - Fax:
Practice Address - Street 1:5 FIRST VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8724
Practice Address - Country:US
Practice Address - Phone:910-235-2713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-24
Last Update Date:2015-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5357225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant