Provider Demographics
NPI:1609379718
Name:ETISOMBA, JEREMY (OTR/L)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:ETISOMBA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 TRADE SQ W APT 8
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1282
Mailing Address - Country:US
Mailing Address - Phone:919-667-7815
Mailing Address - Fax:
Practice Address - Street 1:1840 W HIGH ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-9399
Practice Address - Country:US
Practice Address - Phone:937-773-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT010001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist