Provider Demographics
NPI:1306396197
Name:BENNETT, JESSICA DALE (COTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DALE
Last Name:BENNETT
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 1:1360 N 13TH ST APT 28C
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-3071
Mailing Address - Country:US
Mailing Address - Phone:903-851-6670
Mailing Address - Fax:
Practice Address - Street 1:6401 OHIO DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-6700
Practice Address - Country:US
Practice Address - Phone:214-556-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214203224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant