MEDICARE: JILLIAN GRACE MATSON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OC016205	PA

General Provider Information

NPI Number	:	1750935458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN GRACE MATSON OTR/L

Provider Business Mailing Address
First Line	:	2331 E SUSQUEHANNA AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-2930
Country	:	US
Telephone Number	:	240-793-7320
Fax Number	:

Provider Business Practice Location Address
First Line	:	2331 E SUSQUEHANNA AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-2930
Country	:	US
Telephone Number	:	240-793-7320
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2019
Last Update Date	:	07/31/2019

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