Basic Information
| Provider Information | |||||||||
| NPI: | 1871789537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PITASSI | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | VANDAL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, PCS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 169 ASHLEY AVE RM 398 3 SW | ||||||||
| Address2: | PO BOX 250350 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437923481 | ||||||||
| FaxNumber: | 8437920724 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 ASHLEY AVE RM 398 3 SW | ||||||||
| Address2: | PHYSICAL THERAPY DEPT | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437923481 | ||||||||
| FaxNumber: | 8437920724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2007 | ||||||||
| LastUpdateDate: | 09/17/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 1991 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No ID Information.