Provider Demographics
NPI:1770879983
Name:WOOD, JESSICA KRISTEEN (MOT, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:KRISTEEN
Last Name:WOOD
Suffix:
Gender:F
Credentials:MOT, 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:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:101 NW 1ST ST
Practice Address - Street 2:114
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47708-1259
Practice Address - Country:US
Practice Address - Phone:812-402-0444
Practice Address - Fax:812-402-0449
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-26
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005314A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN31005314AOtherOCCUPATIONAL THERAPY LICENSE
KY7100405700Medicaid
ININ3183002Medicare PIN