Provider Demographics
NPI:1831699438
Name:MEDINA, JESSICA LYNN (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:HENRY WOOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:216 E INTERSTATE 2 STE K
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-6505
Mailing Address - Country:US
Mailing Address - Phone:956-588-4060
Mailing Address - Fax:
Practice Address - Street 1:216 E INTERSTATE 2 STE K
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-6505
Practice Address - Country:US
Practice Address - Phone:956-588-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212859224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant