Provider Demographics
NPI:1134365240
Name:JEZOUIT, STACY M (OT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:JEZOUIT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1916
Mailing Address - Country:US
Mailing Address - Phone:860-674-1824
Mailing Address - Fax:860-674-1836
Practice Address - Street 1:230 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1916
Practice Address - Country:US
Practice Address - Phone:860-674-1824
Practice Address - Fax:860-674-1836
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003498225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist