Provider Demographics
NPI:1366732521
Name:DE BRUN, JESSICA NICOLE (MOT, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:DE BRUN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1965 COULSTON ST
Mailing Address - Street 2:UNIT #63
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1740
Mailing Address - Country:US
Mailing Address - Phone:909-800-2049
Mailing Address - Fax:
Practice Address - Street 1:1965 COULSTON ST
Practice Address - Street 2:UNIT #63
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-1740
Practice Address - Country:US
Practice Address - Phone:909-800-2049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11519225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics