Healthcare Provider Details

I. General information

NPI: 1245821909
Provider Name (Legal Business Name): JILLANE RAINES OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73804 E GRAND BLUFF LOOP
KENNEWICK WA
99338-6024
US

IV. Provider business mailing address

73804 E GRAND BLUFF LOOP
KENNEWICK WA
99338-6024
US

V. Phone/Fax

Practice location:
  • Phone: 843-422-0099
  • Fax:
Mailing address:
  • Phone: 843-422-0099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number00000904
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: