Provider Demographics
NPI:1528776226
Name:SALLAWAY, JESSICA NICOLE (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:SALLAWAY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1292 POND LN
Mailing Address - Street 2:
Mailing Address - City:GRAND RIDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32442-4026
Mailing Address - Country:US
Mailing Address - Phone:850-372-7188
Mailing Address - Fax:
Practice Address - Street 1:1344 CROSS CREEK CIR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3728
Practice Address - Country:US
Practice Address - Phone:850-322-8709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18491224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty