Provider Demographics
NPI:1194006601
Name:BOOTHE, JESSICA C
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 PINE ALLEY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1216
Mailing Address - Country:US
Mailing Address - Phone:850-217-2186
Mailing Address - Fax:
Practice Address - Street 1:804 PINE ALLEY ST
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1216
Practice Address - Country:US
Practice Address - Phone:850-217-2186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14340225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist