Provider Demographics
NPI:1285138123
Name:UM, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:UM
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 1:601 MARTIN LUTHER KING JR DR
Mailing Address - Street 2:432 FL ATKINS BLDG
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27110-0001
Mailing Address - Country:US
Mailing Address - Phone:336-750-3174
Mailing Address - Fax:
Practice Address - Street 1:601 MARTIN LUTHER KING JR DR
Practice Address - Street 2:432 FL ATKINS BUILDING
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-0001
Practice Address - Country:US
Practice Address - Phone:336-750-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-18-51065106S00000X
390200000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program