Provider Demographics
NPI:1134479702
Name:GREEN, JESSIE LEE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 FOX TROT DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-8505
Mailing Address - Country:US
Mailing Address - Phone:479-518-3718
Mailing Address - Fax:
Practice Address - Street 1:20 FOX TROT DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-8505
Practice Address - Country:US
Practice Address - Phone:479-518-3718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist