Provider Demographics
NPI:1689836793
Name:WATERS, JESSICA JANELLE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JANELLE
Last Name:WATERS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 COUNTY ROAD 400 E
Mailing Address - Street 2:
Mailing Address - City:NORRIS CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62869-3909
Mailing Address - Country:US
Mailing Address - Phone:618-962-3070
Mailing Address - Fax:
Practice Address - Street 1:216 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1548
Practice Address - Country:US
Practice Address - Phone:618-382-2923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007162225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist