Provider Demographics
NPI:1871277871
Name:BAUTISTA, JESSICA (OT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 BELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-6952
Mailing Address - Country:US
Mailing Address - Phone:732-938-5333
Mailing Address - Fax:732-938-5680
Practice Address - Street 1:4810 BELMAR BLVD
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07753-6952
Practice Address - Country:US
Practice Address - Phone:732-938-5333
Practice Address - Fax:732-938-5680
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01122700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist