Provider Demographics
NPI:1821217522
Name:DESTEFANO, JESSIE BILLINGS (OTRL)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:BILLINGS
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 N FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-3034
Mailing Address - Country:US
Mailing Address - Phone:802-236-2047
Mailing Address - Fax:
Practice Address - Street 1:365 N FULTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-3034
Practice Address - Country:US
Practice Address - Phone:802-236-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016284-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist