Provider Demographics
NPI:1619953221
Name:DESMARAIS, JON ANTHONY (PT)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:ANTHONY
Last Name:DESMARAIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E COLFAX AVE
Mailing Address - Street 2:STE. 102
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2737
Mailing Address - Country:US
Mailing Address - Phone:574-234-1059
Mailing Address - Fax:574-234-1068
Practice Address - Street 1:401 E COLFAX AVE
Practice Address - Street 2:STE. 102
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2737
Practice Address - Country:US
Practice Address - Phone:574-234-1059
Practice Address - Fax:574-234-1068
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006317A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist