Provider Demographics
NPI:1952437063
Name:BOTT, JESSICA ROSE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:BOTT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 CAROLANE
Mailing Address - Street 2:
Mailing Address - City:KINGSLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49649-8702
Mailing Address - Country:US
Mailing Address - Phone:231-735-1146
Mailing Address - Fax:
Practice Address - Street 1:5246 N ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6984
Practice Address - Country:US
Practice Address - Phone:231-929-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer