Healthcare Provider Details

I. General information

NPI: 1124377056
Provider Name (Legal Business Name): JILLIAN M. KRUEGER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

100 JOSEPH WALKER DR.
WEST COLUMBIA SC
29169
US

IV. Provider business mailing address

PO BOX 38
MIAMIVILLE OH
45147-0038
US

V. Phone/Fax

Practice location:
  • Phone: 803-356-1303
  • Fax:
Mailing address:
  • Phone: 513-560-0045
  • Fax: 513-831-1362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3107
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number03957
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: