Provider Demographics
NPI:1942068085
Name:JESSE, CHRISTIAN BLAKE (OTA)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:BLAKE
Last Name:JESSE
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 POST OAK DR
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35023-5795
Mailing Address - Country:US
Mailing Address - Phone:256-531-4410
Mailing Address - Fax:
Practice Address - Street 1:420 DEAN DR
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2763
Practice Address - Country:US
Practice Address - Phone:205-631-8709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2703224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant