Provider Demographics
NPI:1144982661
Name:WYATT, JA'NICE NICOLE (OTR)
Entity type:Individual
Prefix:
First Name:JA'NICE
Middle Name:NICOLE
Last Name:WYATT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 TECHNOLOGY FOREST BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-2008
Mailing Address - Country:US
Mailing Address - Phone:832-463-2489
Mailing Address - Fax:
Practice Address - Street 1:1001 MEDICAL PLAZA DR STE 140
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-3209
Practice Address - Country:US
Practice Address - Phone:281-367-2035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122115225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty