Provider Demographics
NPI:1699191742
Name:CARVALHO, JESSICA SOUSA (COTA/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SOUSA
Last Name:CARVALHO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LUPI CT
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4761
Mailing Address - Country:US
Mailing Address - Phone:386-447-0011
Mailing Address - Fax:386-447-0161
Practice Address - Street 1:31 LUPI CT
Practice Address - Street 2:SUITE 150
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4761
Practice Address - Country:US
Practice Address - Phone:386-447-0011
Practice Address - Fax:386-447-0161
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12553224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant