Healthcare Provider Details

I. General information

NPI: 1508332958
Provider Name (Legal Business Name): JILL SUZANNE PAINTER MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 06/20/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1591 N MANSFIELD PL
EAGLE ID
83616-6649
US

IV. Provider business mailing address

1591 N MANSFIELD PL
EAGLE ID
83616-6649
US

V. Phone/Fax

Practice location:
  • Phone: 408-865-1365
  • Fax:
Mailing address:
  • Phone: 408-865-1365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-2451
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number10422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: