Provider Demographics
NPI:1619600418
Name:JESTER, MALLORY BROOKE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:BROOKE
Last Name:JESTER
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 1:221 ALABASTER ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4432
Mailing Address - Country:US
Mailing Address - Phone:757-641-8338
Mailing Address - Fax:
Practice Address - Street 1:3181 SHORE DR STE 201
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1129
Practice Address - Country:US
Practice Address - Phone:757-496-1653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131001364224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant