Provider Demographics
NPI:1396026027
Name:WICKER, JESSICA MORTIN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MORTIN
Last Name:WICKER
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 1:1350 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3224
Mailing Address - Country:US
Mailing Address - Phone:321-434-7182
Mailing Address - Fax:321-434-8586
Practice Address - Street 1:1350 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-7182
Practice Address - Fax:321-434-8586
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10380225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist