Provider Demographics
NPI:1134396583
Name:JACESKO, JENNIFER C (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:JACESKO
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5704 MAGELLAN WAY
Mailing Address - Street 2:APT 303
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 COLLINGTON DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-5836
Practice Address - Country:US
Practice Address - Phone:919-460-6500
Practice Address - Fax:919-272-4410
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5469225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist