Provider Demographics
NPI:1790207686
Name:JANSSON, JESSICA (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JANSSON
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 MOUNTAINSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:CUMBOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17930-0022
Mailing Address - Country:US
Mailing Address - Phone:570-621-8794
Mailing Address - Fax:
Practice Address - Street 1:1103 MOUNTAINSIDE ROAD
Practice Address - Street 2:
Practice Address - City:CUMBOLA
Practice Address - State:PA
Practice Address - Zip Code:17930-0022
Practice Address - Country:US
Practice Address - Phone:570-621-8794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC014777225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA28636246OtherDRIVERS LICENSE