Basic Information
| Provider Information | |||||||||
| NPI: | 1275961146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 PARK ST APT 301 | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985842277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014151323 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2430 N 13TH ST | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985841213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604261651 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2013 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OC60278165 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.