Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 943 | WV |
NPI | 1003241936 |
---|---|
Provider Name | Jennifer Destito |
First Address | Clarksburg, WV 26301-1989 |
Second Address | Clarksburg, WV 26301 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2013 |
Last Update Date | 11/09/2013 |