Healthcare Provider Details

I. General information

NPI: 1922625904
Provider Name (Legal Business Name): JILLIAN MARCUCCI M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63311 JAMISON ST
BEND OR
97703-8288
US

IV. Provider business mailing address

2577 NE COURTNEY DR
BEND OR
97701-7752
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-7500
  • Fax: 541-322-7565
Mailing address:
  • Phone: 541-322-7500
  • Fax: 541-322-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number451605
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: