Provider Demographics
NPI:1528487840
Name:WILCOCK, JESSE (OTR/L)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:WILCOCK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:SUITE A & B
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-7013
Mailing Address - Country:US
Mailing Address - Phone:928-367-5779
Mailing Address - Fax:928-367-5778
Practice Address - Street 1:218 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE A & B
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-7013
Practice Address - Country:US
Practice Address - Phone:928-367-5779
Practice Address - Fax:928-367-5778
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5751225XP0200X, 225XP0019X, 225XM0800X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health