Provider Demographics
NPI:1215611819
Name:BERRY, JESSICA MARIE I (COTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:BERRY
Suffix:I
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1531 MAUREEN DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4614
Mailing Address - Country:US
Mailing Address - Phone:618-964-5704
Mailing Address - Fax:
Practice Address - Street 1:1700 WHITE ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-4349
Practice Address - Country:US
Practice Address - Phone:618-242-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005908224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant