Provider Demographics
NPI:1366852881
Name:SHIELDS, JESSICA MARIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:ADSIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:455 GRIZZLY STREET
Mailing Address - Street 2:
Mailing Address - City:AUMSVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97325
Mailing Address - Country:US
Mailing Address - Phone:518-390-4910
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:MILWACKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:971-206-5202
Practice Address - Fax:971-206-5263
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR324241225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist