Provider Demographics
NPI:1982731501
Name:FASNACHT, JENNIFER A (OT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:FASNACHT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 W 1ST ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MONTICELLO
Mailing Address - State:IA
Mailing Address - Zip Code:52310-1307
Mailing Address - Country:US
Mailing Address - Phone:319-465-3059
Mailing Address - Fax:319-465-4070
Practice Address - Street 1:818 W 1ST ST
Practice Address - Street 2:SUITE 301
Practice Address - City:MONTICELLO
Practice Address - State:IA
Practice Address - Zip Code:52310-1307
Practice Address - Country:US
Practice Address - Phone:319-465-3059
Practice Address - Fax:319-465-4070
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01180225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist