Provider Demographics
NPI:1235691528
Name:MONTES FONSECA, JESMARIE (OTA)
Entity Type:Individual
Prefix:
First Name:JESMARIE
Middle Name:
Last Name:MONTES FONSECA
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9744
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00908-0744
Mailing Address - Country:US
Mailing Address - Phone:787-303-9662
Mailing Address - Fax:
Practice Address - Street 1:759 AVE AVELINO VICENTE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-2538
Practice Address - Country:US
Practice Address - Phone:787-303-9662
Practice Address - Fax:787-303-8666
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2175-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2175-1OtherLICENSE