Provider Demographics
NPI:1528317161
Name:ELAM, JESSICA DAWN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:ELAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7330 E MOUNT EDEN RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-5315
Mailing Address - Country:US
Mailing Address - Phone:812-820-0081
Mailing Address - Fax:
Practice Address - Street 1:900 ANSON ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-1982
Practice Address - Country:US
Practice Address - Phone:812-820-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002237224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant