Provider Demographics
NPI:1922026210
Name:OTTO, JESSICA CATHERINE (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CATHERINE
Last Name:OTTO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 SPRUCE ST
Mailing Address - Street 2:STE. 3E
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5701
Mailing Address - Country:US
Mailing Address - Phone:215-829-8484
Mailing Address - Fax:215-829-8441
Practice Address - Street 1:801 SPRUCE ST
Practice Address - Street 2:SPRUCE BUILDING, SUITE 3E
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5701
Practice Address - Country:US
Practice Address - Phone:215-829-8484
Practice Address - Fax:215-829-8441
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-11-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAOS010021L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA085824Medicare PIN
PAH39313Medicare UPIN