Provider Demographics
NPI:1477039634
Name:NICHOLSON, JESSICA VOGEL (COTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:VOGEL
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 BEAVERDALE LN
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3912
Mailing Address - Country:US
Mailing Address - Phone:407-733-0555
Mailing Address - Fax:
Practice Address - Street 1:2425 20TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6615
Practice Address - Country:US
Practice Address - Phone:772-778-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11679224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant