Provider Demographics
NPI:1083850614
Name:DACULES, JESSAMINE BALAGON (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JESSAMINE
Middle Name:BALAGON
Last Name:DACULES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:JESSAMINE
Other - Middle Name:B
Other - Last Name:DACULES- ALIVIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:111 MANCOS DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7085
Mailing Address - Country:US
Mailing Address - Phone:717-609-5718
Mailing Address - Fax:
Practice Address - Street 1:149 KLATTENHOFF LN
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-4638
Practice Address - Country:US
Practice Address - Phone:512-840-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-03
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008318225X00000X
TX112937225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist