Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 5751 | AZ |
N | 225XM0800X | Mental Health | 5751 | AZ |
N | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 5751 | AZ |
N | 225XP0200X | Occupational Therapist - Pediatrics | 5751 | AZ |
NPI | 1528487840 |
---|---|
Provider Name | Jesse Wilcock |
First Address | Lakeside, AZ 85929-7013 |
Second Address | Lakeside, AZ 85929-7013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2014 |
Last Update Date | 15/04/2014 |