Provider Demographics
NPI:1003189697
Name:ERICKSON, JILLIAN (PT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 HANSHAW RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1589
Mailing Address - Country:US
Mailing Address - Phone:607-229-4086
Mailing Address - Fax:607-273-4972
Practice Address - Street 1:840 HANSHAW RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1589
Practice Address - Country:US
Practice Address - Phone:607-229-4086
Practice Address - Fax:607-273-4972
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist