Provider Demographics
NPI:1588145627
Name:HERNANDEZ, JESSICA (MOT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16808 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1504
Mailing Address - Country:US
Mailing Address - Phone:347-484-1805
Mailing Address - Fax:
Practice Address - Street 1:16808 29TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1504
Practice Address - Country:US
Practice Address - Phone:347-484-1805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP12910225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist