Provider Demographics
NPI:1407528623
Name:FONTENAULT, JESSIE LYNN (OTD, OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:JESSIE
Middle Name:LYNN
Last Name:FONTENAULT
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 COLWELL RD
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02830-1861
Mailing Address - Country:US
Mailing Address - Phone:401-678-6586
Mailing Address - Fax:
Practice Address - Street 1:765 ALLENS AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-5443
Practice Address - Country:US
Practice Address - Phone:401-432-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT02015225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist