Provider Demographics
NPI:1194018473
Name:HAGAN, JESSICA (COTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 REMINGTON PARK CT
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-5317
Mailing Address - Country:US
Mailing Address - Phone:615-484-9159
Mailing Address - Fax:
Practice Address - Street 1:278 DRY VALLEY RD
Practice Address - Street 2:
Practice Address - City:ALGOOD
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-537-9524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA0000001973224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant