Provider Demographics
NPI:1447689773
Name:DAVIDSON, JESSICA ELIZABETH (OTA)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-2001
Mailing Address - Country:US
Mailing Address - Phone:914-374-5383
Mailing Address - Fax:
Practice Address - Street 1:33 DAVIS AVE
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-2001
Practice Address - Country:US
Practice Address - Phone:914-374-5383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007604-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor