Basic Information
| Provider Information | |||||||||
| NPI: | 1790222099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 170 W RAINBOW RIDGE DR | ||||||||
| Address2: | 411 | ||||||||
| City: | OAK CREEK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531542961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142025251 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3216 W HIGHLAND BLVD | ||||||||
| Address2: | (414) 344-6515 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532083252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143446515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2017 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
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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 | 225X00000X | 5854-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1740689710 | 05 | WI | MEDICAID |