Provider Demographics
NPI:1093449860
Name:LASAM, JELLE MARIE TOLENTINO
Entity Type:Individual
Prefix:
First Name:JELLE MARIE
Middle Name:TOLENTINO
Last Name:LASAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 KINGSBURY DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2021
Mailing Address - Country:US
Mailing Address - Phone:202-766-3986
Mailing Address - Fax:
Practice Address - Street 1:4656 LIVINGSTON RD SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3149
Practice Address - Country:US
Practice Address - Phone:202-519-0982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist