Provider Demographics
NPI:1174937890
Name:DESISTO, JENNIFER (OT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:DESISTO
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 1:8 PAGE PL
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-3850
Mailing Address - Country:US
Mailing Address - Phone:207-213-0575
Mailing Address - Fax:
Practice Address - Street 1:24 MAIN RD N
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444-1306
Practice Address - Country:US
Practice Address - Phone:207-862-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2823225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist