Provider Demographics
NPI:1770918161
Name:DOTY, JESSIANNE (DPT)
Entity type:Individual
Prefix:
First Name:JESSIANNE
Middle Name:
Last Name:DOTY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1676 PORTVILLE OBI RD
Mailing Address - Street 2:
Mailing Address - City:PORTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14770-9612
Mailing Address - Country:US
Mailing Address - Phone:716-307-8979
Mailing Address - Fax:
Practice Address - Street 1:1676 PORTVILLE OBI RD
Practice Address - Street 2:
Practice Address - City:PORTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14770-9612
Practice Address - Country:US
Practice Address - Phone:716-307-8979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist