Provider Demographics
NPI:1932402641
Name:BACON, JESSICA (OTR)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 CHICOPEE ST
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01013-2148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:546 CHICOPEE ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01013-2148
Practice Address - Country:US
Practice Address - Phone:413-546-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9958225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist