Provider Demographics
NPI:1801416128
Name:BEDOYA, JESSICA (OTR)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BEDOYA
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 1:395 SUNKEN MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-1000
Mailing Address - Country:US
Mailing Address - Phone:631-269-5800
Mailing Address - Fax:
Practice Address - Street 1:395 SUNKEN MEADOW RD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-1000
Practice Address - Country:US
Practice Address - Phone:631-269-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024704225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY437046OtherNBCOT
NY024704OtherNEW YORK STATE OFFICE OF THE PROFESSIONS