Provider Demographics
NPI:1386136372
Name:DEJEAN, ANDREA JO (OTR)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:JO
Last Name:DEJEAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 N MOUND ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4427
Mailing Address - Country:US
Mailing Address - Phone:936-564-6907
Mailing Address - Fax:
Practice Address - Street 1:817 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4427
Practice Address - Country:US
Practice Address - Phone:936-554-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117351225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist