Provider Demographics
NPI:1588639355
Name:DETTORE, JESSICA SUE (ATC, MED)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUE
Last Name:DETTORE
Suffix:
Gender:F
Credentials:ATC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BAYWOOD AVE
Mailing Address - Street 2:APT. 7B
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15228-1349
Mailing Address - Country:US
Mailing Address - Phone:724-494-3234
Mailing Address - Fax:
Practice Address - Street 1:3200 S WATER ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15203-2307
Practice Address - Country:US
Practice Address - Phone:412-432-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0036972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer