Basic Information
| Provider Information | |||||||||
| NPI: | 1245888486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UMHOLTZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 307 SAGAMORE PKWY W | ||||||||
| Address2: | |||||||||
| City: | WEST LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479061500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654632200 | ||||||||
| FaxNumber: | 7654633625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2019 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 32003104A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.