Provider Demographics
NPI:1992387021
Name:STAG, JESSICA (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STAG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 ROMANCOKE RD
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21666-2640
Mailing Address - Country:US
Mailing Address - Phone:410-253-4026
Mailing Address - Fax:
Practice Address - Street 1:22317 DUPONT BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-2153
Practice Address - Country:US
Practice Address - Phone:302-253-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09266225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist