Provider Demographics
NPI:1629509427
Name:LANE, JESSICA ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:LANE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ELIZABETH
Other - Last Name:ROLLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L COTA
Mailing Address - Street 1:519 YORK RD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:IN
Mailing Address - Zip Code:46932-9775
Mailing Address - Country:US
Mailing Address - Phone:765-480-8161
Mailing Address - Fax:
Practice Address - Street 1:751 W 2ND ST STE 200
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1385
Practice Address - Country:US
Practice Address - Phone:765-919-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003154A225X00000X
IN31007603A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist