Provider Demographics
NPI:1952838534
Name:DEGROOT, JESSICA MARIE (OTR)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:DEGROOT
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 1:11 ALGOMA ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3601
Mailing Address - Country:US
Mailing Address - Phone:920-979-0194
Mailing Address - Fax:
Practice Address - Street 1:614 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CHILTON
Practice Address - State:WI
Practice Address - Zip Code:53014-1568
Practice Address - Country:US
Practice Address - Phone:920-849-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6006225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist