Healthcare Provider Details

I. General information

NPI: 1134654478
Provider Name (Legal Business Name): JILL PETERSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILL PETERSON INGWELL

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FAIRVIEW LN
SONORA CA
95370-4809
US

IV. Provider business mailing address

4632 BAYVIEW DR
COPPEROPOLIS CA
95228-9435
US

V. Phone/Fax

Practice location:
  • Phone: 209-536-2000
  • Fax:
Mailing address:
  • Phone: 701-430-4013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number18661
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-1675
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: