Healthcare Provider Details

I. General information

NPI: 1316644586
Provider Name (Legal Business Name): JILLIAN ZUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 VICTORY RD
BOSTON MA
02122-3518
US

IV. Provider business mailing address

233 FREEMAN ST APT 2
BROOKLINE MA
02446-6792
US

V. Phone/Fax

Practice location:
  • Phone: 617-371-3010
  • Fax:
Mailing address:
  • Phone: 916-642-6674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number14743
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: