Healthcare Provider Details

I. General information

NPI: 1215084371
Provider Name (Legal Business Name): MRS. JILL MARIE OLIVIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JILL MARIE KENNING

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 BEACH BLVD
JACKSONVILLE FL
32207-3704
US

IV. Provider business mailing address

4836 ASHLEY MANOR WAY W
JACKSONVILLE FL
32225-4039
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-1462
  • Fax: 904-396-1199
Mailing address:
  • Phone: 904-807-9592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: