Provider Demographics
NPI:1972845261
Name:DIVIESTI, JESSICA M (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:DIVIESTI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 SAFSTROM DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4107
Mailing Address - Country:US
Mailing Address - Phone:208-520-2120
Mailing Address - Fax:
Practice Address - Street 1:935 SAFSTROM DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4107
Practice Address - Country:US
Practice Address - Phone:208-520-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-820225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist