Healthcare Provider Details

I. General information

NPI: 1184749608
Provider Name (Legal Business Name): JILL ELIZABETH FENNELLY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 WELSH RD
PHILADELPHIA PA
19115-3730
US

IV. Provider business mailing address

583 GREEN LN
PHILADELPHIA PA
19128-2620
US

V. Phone/Fax

Practice location:
  • Phone: 215-676-9191
  • Fax:
Mailing address:
  • Phone: 610-888-9684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT015306
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: