Provider Demographics
NPI:1518479617
Name:LONGENETTE, JESSICA ELIZABETH (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:LONGENETTE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 FLETCHER RD APT 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-7298
Mailing Address - Country:US
Mailing Address - Phone:304-940-5320
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-2304
Practice Address - Country:US
Practice Address - Phone:304-766-1722
Practice Address - Fax:304-766-8991
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2178224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant