Provider Demographics
NPI:1205407566
Name:PERSAUD, JESSICA ISABELLA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ISABELLA
Last Name:PERSAUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 JACOBS HWY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-7279
Mailing Address - Country:US
Mailing Address - Phone:864-833-2550
Mailing Address - Fax:
Practice Address - Street 1:304 JACOBS HWY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7279
Practice Address - Country:US
Practice Address - Phone:864-833-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5104224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant