Provider Demographics
NPI:1902217599
Name:BOOTH, JESSICA (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 N RAINEY LN
Mailing Address - Street 2:
Mailing Address - City:CAVE CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72521-9261
Mailing Address - Country:US
Mailing Address - Phone:870-307-4736
Mailing Address - Fax:
Practice Address - Street 1:255 N RAINEY LN
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:AR
Practice Address - Zip Code:72521-9261
Practice Address - Country:US
Practice Address - Phone:870-307-4736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant