Provider Demographics
NPI:1497039721
Name:MACK, JESSICA (OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 ALFRED RD E
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3054
Mailing Address - Country:US
Mailing Address - Phone:516-721-4175
Mailing Address - Fax:
Practice Address - Street 1:2000 ALFRED RD E
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3054
Practice Address - Country:US
Practice Address - Phone:516-721-4175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY009501225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator