Provider Demographics
NPI:1285053843
Name:HOLT, JESSICA (COTA/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:412-721-9337
Mailing Address - Fax:
Practice Address - Street 1:1301 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4905
Practice Address - Country:US
Practice Address - Phone:412-721-9337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2042224Z00000X
WAOC60450841224Z00000X
MTOTP-OTA-LIC-8614224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant