Provider Demographics
NPI:1376011122
Name:JESSE, SERA
Entity Type:Individual
Prefix:
First Name:SERA
Middle Name:
Last Name:JESSE
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 1:325 S UNIVERSITY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6164
Mailing Address - Country:US
Mailing Address - Phone:509-921-9798
Mailing Address - Fax:509-921-9774
Practice Address - Street 1:325 S UNIVERSITY RD STE 101
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6164
Practice Address - Country:US
Practice Address - Phone:509-921-9798
Practice Address - Fax:509-921-9774
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOC60679141OtherOT LICENSE