Provider Demographics
NPI:1336511393
Name:LOOSE, JESSICA ROSE (MOTRL)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:LOOSE
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7847 LARSON RD SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOARDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49680-8602
Mailing Address - Country:US
Mailing Address - Phone:810-429-3773
Mailing Address - Fax:
Practice Address - Street 1:3205 SUPPLY RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-9486
Practice Address - Country:US
Practice Address - Phone:231-935-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008393225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist