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General NPI Number Information
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NPI Number | 1528610250
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Entity Type | Individual
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Provider Name | JAMAL OMAR WILLIS
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Gender | Male
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Dates
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Enumeration Date | 07/12/2019
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Last Update Date | 07/12/2019
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Provider Practice Location Address
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Address Line | 2101 BELMONT AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19131-1648
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Country | US
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Telephone | 215-878-3600
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Fax |
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Provider Business Mailing Address
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Address Line | 6636 N BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19126-3222
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Country | US
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Telephone | 267-270-8490
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | TOP009273
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License Number State | PA
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