Provider Demographics
NPI:1669614905
Name:JESSEN, KATHLEEN LEONTINE (OTR/L, IBCLC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LEONTINE
Last Name:JESSEN
Suffix:
Gender:F
Credentials:OTR/L, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1192
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-1192
Mailing Address - Country:US
Mailing Address - Phone:940-208-9198
Mailing Address - Fax:
Practice Address - Street 1:11309 DUSTY TRAIL CT
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-1927
Practice Address - Country:US
Practice Address - Phone:940-208-9198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L302117174N00000X
TX122278225X00000X, 225XP0200X, 225XF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & Swallowing
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics