Provider Demographics
NPI:1659594901
Name:DESJARDINE, JEFF ROGER (PT)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:ROGER
Last Name:DESJARDINE
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 1:4017 W BARCELONA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6701
Mailing Address - Country:US
Mailing Address - Phone:813-598-2424
Mailing Address - Fax:813-251-4290
Practice Address - Street 1:602 S HOWARD AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2413
Practice Address - Country:US
Practice Address - Phone:813-253-2406
Practice Address - Fax:813-251-4290
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist