Basic Information
| Provider Information | |||||||||
| NPI: | 1659594901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESJARDINE | ||||||||
| FirstName: | JEFF | ||||||||
| MiddleName: | ROGER | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4017 W BARCELONA ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336296701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135982424 | ||||||||
| FaxNumber: | 8132514290 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 S HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336062413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132532406 | ||||||||
| FaxNumber: | 8132514290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 03/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT10423 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.