Healthcare Provider Details

I. General information

NPI: 1881138519
Provider Name (Legal Business Name): DIANNE JEZAK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 LONDONDERRY RD
WINDHAM NH
03087-1651
US

IV. Provider business mailing address

16 LONDONDERRY RD
WINDHAM NH
03087-1651
US

V. Phone/Fax

Practice location:
  • Phone: 603-434-8015
  • Fax:
Mailing address:
  • Phone: 603-434-8015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1551M
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1303
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3854
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: