Provider Demographics
NPI:1417411851
Name:MCWHORTER, JESSICA RENE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENE
Last Name:MCWHORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RENE
Other - Last Name:ROAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:164 HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:LOCKESBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71846-9079
Mailing Address - Country:US
Mailing Address - Phone:903-824-3336
Mailing Address - Fax:
Practice Address - Street 1:1008 CITIZENS TRL
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5922
Practice Address - Country:US
Practice Address - Phone:903-824-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A883224Z00000X
TX212654224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant