Provider Demographics
NPI:1457836165
Name:OTTE, JESSICA1 (RBT)
Entity Type:Individual
Prefix:
First Name:JESSICA1
Middle Name:
Last Name:OTTE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27070 SUN CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-2509
Mailing Address - Country:US
Mailing Address - Phone:951-381-0750
Mailing Address - Fax:
Practice Address - Street 1:27070 SUN CITY BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-2509
Practice Address - Country:US
Practice Address - Phone:951-381-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-66017247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty