Provider Demographics
NPI:1801224357
Name:OTT, JESSICA LEA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEA
Last Name:OTT
Suffix:
Gender:F
Credentials:PTA
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Mailing Address - Street 1:1067 S HOVER ST STE E
Mailing Address - Street 2:PMB 187
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1067 S HOVER ST STE E
Practice Address - Street 2:PMB 187
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-7903
Practice Address - Country:US
Practice Address - Phone:828-275-7114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-21
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO13212225200000X
NCA5092225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant