Provider Demographics
NPI:1093210064
Name:AMBROSE, JILLIAN LEE
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEE
Last Name:AMBROSE
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 1:16 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:HARVEYS LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:18618-2215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:417 GROW AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:PA
Practice Address - Zip Code:18801-1105
Practice Address - Country:US
Practice Address - Phone:814-865-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
PART0076682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program