=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366215501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL ANN WRATHER PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2023
-----------------------------------------------------
Last Update Date | 10/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 N HUNTINGTON ST STE 2546
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44256-1863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-290-2121
-----------------------------------------------------
Fax | 216-290-2122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 383 S MILTON ST
-----------------------------------------------------
City | SMITHVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44677-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-465-7261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA-4696
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------