Provider Demographics
NPI:1588065601
Name:DECOTEAU, JENNIFER
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:DECOTEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 CRYSTAL DR
Mailing Address - Street 2:
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026-8705
Mailing Address - Country:US
Mailing Address - Phone:203-520-4418
Mailing Address - Fax:
Practice Address - Street 1:101 BICKFORD EXT
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001
Practice Address - Country:US
Practice Address - Phone:860-269-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003907225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist