Provider Demographics
NPI:1780122077
Name:KIRSCH, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KIRSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MONHEGON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-1808
Mailing Address - Country:US
Mailing Address - Phone:973-975-2068
Mailing Address - Fax:
Practice Address - Street 1:5535 S WILLIAMSON BLVD
Practice Address - Street 2:SUITE 774
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8311
Practice Address - Country:US
Practice Address - Phone:888-265-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225X00000X
NC10688225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist