Provider Demographics
NPI:1982375358
Name:FORTUNE, JESSICA DENISE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DENISE
Last Name:FORTUNE
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 1:20 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:TUPPER LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12986-1604
Mailing Address - Country:US
Mailing Address - Phone:518-524-2603
Mailing Address - Fax:
Practice Address - Street 1:2568 NY-212
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498
Practice Address - Country:US
Practice Address - Phone:845-679-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047491225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist