Provider Demographics
NPI:1053328393
Name:DURHAM, JESSICA A (OT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:A
Last Name:DURHAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:MOSHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT
Mailing Address - Street 1:1409 KINGSLEY AVE
Mailing Address - Street 2:BLDG 3
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4537
Mailing Address - Country:US
Mailing Address - Phone:904-348-5511
Mailing Address - Fax:
Practice Address - Street 1:11560 CHAPMAN HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:SEYMOUR
Practice Address - State:TN
Practice Address - Zip Code:37865-5044
Practice Address - Country:US
Practice Address - Phone:865-577-1914
Practice Address - Fax:865-577-1714
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3468225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3734647OtherGROUP PRICING NUMBER
TN3734647OtherGROUP PRICING NUMBER