Provider Demographics
NPI:1851118699
Name:MIRANDA, JESSICA (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
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 1:9150 W INDIAN SCHOOL RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-2388
Mailing Address - Country:US
Mailing Address - Phone:480-787-5387
Mailing Address - Fax:623-232-3250
Practice Address - Street 1:3941 E BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2750
Practice Address - Country:US
Practice Address - Phone:480-787-5387
Practice Address - Fax:480-320-3537
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-009572225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ175024Medicaid