Provider Demographics
NPI:1548718323
Name:SIRELSON, JESSAMINE REBECCA (COTA/L)
Entity type:Individual
Prefix:
First Name:JESSAMINE
Middle Name:REBECCA
Last Name:SIRELSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:WA
Mailing Address - Zip Code:98244-0095
Mailing Address - Country:US
Mailing Address - Phone:360-383-2012
Mailing Address - Fax:
Practice Address - Street 1:4936 DEMING RD
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:WA
Practice Address - Zip Code:98244
Practice Address - Country:US
Practice Address - Phone:360-383-2012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60687098224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant