Provider Demographics
NPI:1386232155
Name:WALTERS, JESSICA (MS OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 W MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-2306
Mailing Address - Country:US
Mailing Address - Phone:262-354-2732
Mailing Address - Fax:
Practice Address - Street 1:10237 W ENCANTO BLVD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4702
Practice Address - Country:US
Practice Address - Phone:623-772-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008117225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist