Provider Demographics
NPI:1861074890
Name:SPENCER, JESSICA LYNNE (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:SPENCER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6880 BUCKINGHAM BLVD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1709
Mailing Address - Country:US
Mailing Address - Phone:859-750-9420
Mailing Address - Fax:
Practice Address - Street 1:400 PARNASSUS AVE # A-68
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2202
Practice Address - Country:US
Practice Address - Phone:415-353-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246921225X00000X
CA22144225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist