Healthcare Provider Details

I. General information

NPI: 1972852770
Provider Name (Legal Business Name): JANE DESMOND CONNELY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JANE GOODWIN DESMOND

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 SANTA ROSA ST
SAN LUIS OBISPO CA
93405-1811
US

IV. Provider business mailing address

475 POA PL
SAN LUIS OBISPO CA
93405-4768
US

V. Phone/Fax

Practice location:
  • Phone: 949-433-8457
  • Fax:
Mailing address:
  • Phone: 949-433-8457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number13961
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: