Provider Demographics
NPI:1063944486
Name:CHANG, JESSICA EUN (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:EUN
Last Name:CHANG
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 1:9621 LINDENBROOK ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-1120
Mailing Address - Country:US
Mailing Address - Phone:703-470-7153
Mailing Address - Fax:
Practice Address - Street 1:4310 FOREST HILL DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5680
Practice Address - Country:US
Practice Address - Phone:703-278-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119007192225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist