Basic Information
| Provider Information | |||||||||
| NPI: | 1770879983 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | KRISTEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MOT, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 NW 1ST ST | ||||||||
| Address2: | 114 | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477081259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124020444 | ||||||||
| FaxNumber: | 8124020449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2011 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31005314A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 31005314A | 01 | IN | OCCUPATIONAL THERAPY LICENSE | OTHER | 7100405700 | 05 | KY | MEDICAID |