Provider Demographics
NPI:1790222099
Name:HOLMES, JESSICA H (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:H
Last Name:HOLMES
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 1:170 W RAINBOW RIDGE DR
Mailing Address - Street 2:411
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-2961
Mailing Address - Country:US
Mailing Address - Phone:414-202-5251
Mailing Address - Fax:
Practice Address - Street 1:3216 W HIGHLAND BLVD
Practice Address - Street 2:(414) 344-6515
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3252
Practice Address - Country:US
Practice Address - Phone:414-344-6515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5854-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740689710Medicaid