Provider Demographics
NPI:1104198423
Name:TAYLOR, JESSICA MARIE (OTD, OTRL)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:OTD, OTRL
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:1495 W FLECK RD
Mailing Address - Street 2:
Mailing Address - City:SIX LAKES
Mailing Address - State:MI
Mailing Address - Zip Code:48886-9544
Mailing Address - Country:US
Mailing Address - Phone:989-287-0023
Mailing Address - Fax:
Practice Address - Street 1:1524 PORTABELLA TRL
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4006
Practice Address - Country:US
Practice Address - Phone:989-772-2967
Practice Address - Fax:989-779-9060
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007567225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist