Provider Demographics
NPI:1497280747
Name:TAKATSUKI, JESSICA Y (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:Y
Last Name:TAKATSUKI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2093
Mailing Address - Fax:
Practice Address - Street 1:55 SPRING ST
Practice Address - Street 2:SUITE A
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8926
Practice Address - Country:US
Practice Address - Phone:207-396-7337
Practice Address - Fax:207-885-4349
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4518225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist