Provider Demographics
NPI:1053729996
Name:DESCOTEAUX, JILLIAN (AT)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:DESCOTEAUX
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 KNIGHT ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3272
Mailing Address - Country:US
Mailing Address - Phone:603-714-9480
Mailing Address - Fax:
Practice Address - Street 1:14 KNIGHT ST
Practice Address - Street 2:UNIT 2
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3272
Practice Address - Country:US
Practice Address - Phone:603-714-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0042922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer