Provider Demographics
NPI:1235348186
Name:DACOSTA, JENNIFER LIANNE (OT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LIANNE
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-5053
Mailing Address - Country:US
Mailing Address - Phone:401-392-0511
Mailing Address - Fax:
Practice Address - Street 1:735 PUTNAM PIKE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:RI
Practice Address - Zip Code:02828-1435
Practice Address - Country:US
Practice Address - Phone:401-949-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT00939225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist