Healthcare Provider Details

I. General information

NPI: 1376798827
Provider Name (Legal Business Name): JILL DAVIS O.T.R.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W 83RD ST #5C
NEW YORK NY
10024-4909
US

IV. Provider business mailing address

222 WEST 83RD STREET #5C
NY NY
10024
US

V. Phone/Fax

Practice location:
  • Phone: 212-580-4275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number012918-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number012918-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: