Provider Demographics
NPI:1326279142
Name:CUSACK, JESSICA DESIREE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DESIREE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:DESIREE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4815 N ASSEMBLY ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6185
Mailing Address - Country:US
Mailing Address - Phone:509-434-6762
Mailing Address - Fax:
Practice Address - Street 1:4815 N ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6185
Practice Address - Country:US
Practice Address - Phone:509-434-6762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00004301225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist