Basic Information
| Provider Information | |||||||||
| NPI: | 1831463785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OUELLETTE | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | MARAK | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 867 W POND MEADOW RD | ||||||||
| Address2: | |||||||||
| City: | WESTBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064982836 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 PEQUOT PARK RD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | WESTBROOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064982856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603996411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2012 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 000189 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.