Provider Demographics
NPI:1063976199
Name:METCALF, JESSICA MARIE (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:METCALF
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:METCALF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RODGERS
Mailing Address - Street 1:721 DUNAWAY LN
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-2605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 DUNAWAY LN # NA
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-2605
Practice Address - Country:US
Practice Address - Phone:817-444-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212615224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX212615OtherCOTA LICENSE