Provider Demographics
NPI:1881138519
Name:JEZAK, DIANNE (OTR/L)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:JEZAK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 LONDONDERRY RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-1651
Mailing Address - Country:US
Mailing Address - Phone:603-434-8015
Mailing Address - Fax:
Practice Address - Street 1:16 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087-1651
Practice Address - Country:US
Practice Address - Phone:603-434-8015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1551M225700000X
NH1303225X00000X
MA3854225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist