Provider Demographics
NPI:1972852770
Name:CONNELY, JANE DESMOND (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:DESMOND
Last Name:CONNELY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:GOODWIN
Other - Last Name:DESMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:475 POA PL
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-4768
Mailing Address - Country:US
Mailing Address - Phone:949-433-8457
Mailing Address - Fax:
Practice Address - Street 1:47 SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1811
Practice Address - Country:US
Practice Address - Phone:949-433-8457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13961225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13961OtherCBOT