Provider Demographics
NPI:1083106777
Name:BOWER, JILLIAN (BS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:BOWER
Suffix:
Gender:F
Credentials:BS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5523 N 825 E
Mailing Address - Street 2:
Mailing Address - City:OTTERBEIN
Mailing Address - State:IN
Mailing Address - Zip Code:47970-8054
Mailing Address - Country:US
Mailing Address - Phone:765-438-7605
Mailing Address - Fax:
Practice Address - Street 1:5523 N 825 E
Practice Address - Street 2:
Practice Address - City:OTTERBEIN
Practice Address - State:IN
Practice Address - Zip Code:47970-8054
Practice Address - Country:US
Practice Address - Phone:765-438-7605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002344A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty