Provider Demographics
NPI:1639653322
Name:FREEMAN, JESSICA TINA (MS OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:TINA
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:TINA
Other - Last Name:CONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS OTR/L
Mailing Address - Street 1:PO BOX 9578
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158-9578
Mailing Address - Country:US
Mailing Address - Phone:530-543-5896
Mailing Address - Fax:530-544-6512
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7008
Practice Address - Country:US
Practice Address - Phone:530-600-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOT-2109225X00000X
CA18537225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist