Provider Demographics
NPI:1417449620
Name:PEDRYS, JESSICA DIANNE (MS, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:DIANNE
Last Name:PEDRYS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21741 EDMUNTON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3526
Mailing Address - Country:US
Mailing Address - Phone:810-292-5033
Mailing Address - Fax:
Practice Address - Street 1:261 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2417
Practice Address - Country:US
Practice Address - Phone:313-745-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008095225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201008095OtherOCCUPATIONAL THERAPIST