Provider Demographics
NPI:1720849151
Name:PHAM, JESSICA BREANNE (OTR, MOT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BREANNE
Last Name:PHAM
Suffix:
Gender:F
Credentials:OTR, MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 LONGMONT DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-1345
Mailing Address - Country:US
Mailing Address - Phone:254-495-0939
Mailing Address - Fax:
Practice Address - Street 1:700 E STATE HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5236
Practice Address - Country:US
Practice Address - Phone:817-873-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist