Provider Demographics
NPI:1871533042
Name:WEATHERSPOON, KENYA DELISA (OT)
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:DELISA
Last Name:WEATHERSPOON
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 1:1500 E. WOODROW WILSON DRIVE
Mailing Address - Street 2:C/O OCCUPATIONAL THERAPY 117
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-968-3904
Practice Address - Street 1:1500 E. WOODROW WILSON DRIVE
Practice Address - Street 2:C/O OCCUPATIONAL THERAPY 117
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-968-3904
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0262225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist