Provider Demographics
NPI:1164764098
Name:LAGUE, JESSICA (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LAGUE
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:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:WAITSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05673-1005
Mailing Address - Country:US
Mailing Address - Phone:802-730-7737
Mailing Address - Fax:
Practice Address - Street 1:1940 BONITA DR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-5524
Practice Address - Country:US
Practice Address - Phone:831-684-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 8304225X00000X
VT072.0074914225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist