Healthcare Provider Details

I. General information

NPI: 1083065270
Provider Name (Legal Business Name): JILLIAN DAGRACA RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 VENETIAN CT SUITE 1
NAPLES FL
34109-8712
US

IV. Provider business mailing address

6360 TECHSTER BLVD SUITE 1
FORT MYERS FL
33966-4805
US

V. Phone/Fax

Practice location:
  • Phone: 239-223-2751
  • Fax: 239-561-2933
Mailing address:
  • Phone: 239-223-2751
  • Fax: 239-561-2933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: