Provider Demographics
NPI:1912291048
Name:IDEN, JESSICA A (COTA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:A
Last Name:IDEN
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 1:900 PROVIDENT DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3252
Mailing Address - Country:US
Mailing Address - Phone:574-371-2500
Mailing Address - Fax:574-371-2779
Practice Address - Street 1:900 PROVIDENT DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3252
Practice Address - Country:US
Practice Address - Phone:574-371-2500
Practice Address - Fax:574-371-2779
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001333A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant