Provider Demographics
NPI:1003491481
Name:COLLINS, JILL IVORY (MSPT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:IVORY
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10160 BELLAVISTA CIR APT 1201
Mailing Address - Street 2:
Mailing Address - City:MIROMAR LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8983
Mailing Address - Country:US
Mailing Address - Phone:586-634-5695
Mailing Address - Fax:
Practice Address - Street 1:14421 METROPOLIS AVE STE 103
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4323
Practice Address - Country:US
Practice Address - Phone:239-561-2778
Practice Address - Fax:239-561-8107
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT24732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty