Provider Demographics
NPI:1235575317
Name:REID, JESSICA L
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:REID
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 1:3804 GOWANDA ZOAR RD
Mailing Address - Street 2:
Mailing Address - City:GOWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14070-9733
Mailing Address - Country:US
Mailing Address - Phone:716-532-5433
Mailing Address - Fax:
Practice Address - Street 1:501 FAIR OAK ST
Practice Address - Street 2:
Practice Address - City:LITTLE VALLEY
Practice Address - State:NY
Practice Address - Zip Code:14755-1120
Practice Address - Country:US
Practice Address - Phone:716-938-6499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018166-1225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist