Provider Demographics
NPI:1356634430
Name:FISK, JENESSA (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENESSA
Middle Name:
Last Name:FISK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 FEDERAL ST
Mailing Address - Street 2:APT 1
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUXTON
Practice Address - State:ME
Practice Address - Zip Code:04093
Practice Address - Country:US
Practice Address - Phone:207-929-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATT60155766225X00000X
MEOT2561225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist