Provider Demographics
NPI:1043773955
Name:OTAH, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OTAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 MOCKINGBIRD HILL CT
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:TX
Mailing Address - Zip Code:75094-3255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9835 N LAKE CREEK PKWY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-6210
Practice Address - Country:US
Practice Address - Phone:737-229-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA186224207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology