Provider Demographics
NPI:1003146309
Name:JESSE, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:JESSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 SUNRISE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 CAHABA VALLEY PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-2216
Practice Address - Country:US
Practice Address - Phone:205-942-6820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALOT9075225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist