Provider Demographics
NPI:1629317870
Name:WHYDE, JESSICA THERESE (MOT, OTR)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:THERESE
Last Name:WHYDE
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5942 W PORT DR
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-9351
Mailing Address - Country:US
Mailing Address - Phone:616-446-8848
Mailing Address - Fax:
Practice Address - Street 1:13485 CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-3602
Practice Address - Country:US
Practice Address - Phone:317-594-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005432A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist