Provider Demographics
NPI:1366855819
Name:OTTE, JESSICA (MPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OTTE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16508 BIRCH FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1831
Mailing Address - Country:US
Mailing Address - Phone:314-435-2190
Mailing Address - Fax:
Practice Address - Street 1:13230 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-1706
Practice Address - Country:US
Practice Address - Phone:314-821-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007004516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist