=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558453555
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER ANNA LASSONDE MOTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 02/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 DEBARTOLO PL SUITE 200
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-7011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-965-7828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 DIANA DR
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44514-3712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-774-5609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT.006660
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------