Provider Demographics
NPI:1679144778
Name:ELDER, JESSIE A (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:A
Last Name:ELDER
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 1:4601 BERGAMOT DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:MO
Mailing Address - Zip Code:63050-2558
Mailing Address - Country:US
Mailing Address - Phone:636-524-2876
Mailing Address - Fax:
Practice Address - Street 1:214 HARTMAN PL STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-2458
Practice Address - Country:US
Practice Address - Phone:636-629-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017005582224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant