Healthcare Provider Details

I. General information

NPI: 1346534427
Provider Name (Legal Business Name): JILL SELF PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 GLENDALE ST
JONESBORO AR
72401-4455
US

IV. Provider business mailing address

91 COUNTY ROAD 620
JONESBORO AR
72404-8694
US

V. Phone/Fax

Practice location:
  • Phone: 870-933-9528
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2503
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: