Provider Demographics
NPI:1245888486
Name:UMHOLTZ, JESSICA ELAINE (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:UMHOLTZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:
Practice Address - Street 1:307 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1500
Practice Address - Country:US
Practice Address - Phone:765-463-2200
Practice Address - Fax:765-463-3625
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003104A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty