Provider Demographics
NPI:1265720304
Name:BAZAR, JESSICA (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BAZAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4430
Mailing Address - Country:US
Mailing Address - Phone:401-946-4250
Mailing Address - Fax:401-275-5645
Practice Address - Street 1:727 EAST AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-6184
Practice Address - Country:US
Practice Address - Phone:401-365-6800
Practice Address - Fax:401-365-6939
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist