Healthcare Provider Details

I. General information

NPI: 1558694869
Provider Name (Legal Business Name): JILL ANN YANICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL A KAUFFMAN

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SAINT PATRICKS DR SUITE 401
WALDORF MD
20603-4527
US

IV. Provider business mailing address

10 SAINT PATRICKS DR SUITE 401
WALDORF MD
20603-4527
US

V. Phone/Fax

Practice location:
  • Phone: 301-870-7366
  • Fax: 301-870-6717
Mailing address:
  • Phone: 301-870-7366
  • Fax: 301-870-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number05264
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: