Provider Demographics
NPI:1326392077
Name:FAIR, JESSICA S
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
Last Name:FAIR
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 1:648 CUMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-1386
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 CORPORATE DR
Practice Address - Street 2:SUITE 280
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334-3634
Practice Address - Country:US
Practice Address - Phone:954-636-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2021-03-25
Deactivation Date:2018-03-02
Deactivation Code:
Reactivation Date:2021-03-25
Provider Licenses
StateLicense IDTaxonomies
VA013100168224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant