Provider Demographics
NPI:1033529177
Name:SIMON, JILLANNA (LAT, ATC, PES)
Entity Type:Individual
Prefix:MS
First Name:JILLANNA
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:LAT, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 HIGLEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST MARLBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05363-9512
Mailing Address - Country:US
Mailing Address - Phone:802-258-7806
Mailing Address - Fax:
Practice Address - Street 1:2230 HIGLEY HILL RD
Practice Address - Street 2:
Practice Address - City:WEST MARLBORO
Practice Address - State:VT
Practice Address - Zip Code:05363-9512
Practice Address - Country:US
Practice Address - Phone:802-258-7806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0055222255A2300X
VT104.00811902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer