Provider Demographics
NPI:1912333667
Name:OTTER, JESSICA LEE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:OTTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 35TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-1712
Mailing Address - Country:US
Mailing Address - Phone:319-377-7331
Mailing Address - Fax:
Practice Address - Street 1:1260 35TH ST STE 1
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-1712
Practice Address - Country:US
Practice Address - Phone:319-377-7331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA006645225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist