Provider Demographics
NPI:1124775838
Name:POLONSKI, JESSICA MARIE (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:POLONSKI
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 SUSAN DR APT G1
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-6131
Mailing Address - Country:US
Mailing Address - Phone:650-303-3601
Mailing Address - Fax:
Practice Address - Street 1:3100 NORIEGA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-4046
Practice Address - Country:US
Practice Address - Phone:703-801-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5942224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant