Provider Demographics
NPI:1134517717
Name:CARR, JILLIAN SARA-RATAJ (PT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:SARA-RATAJ
Last Name:CARR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:RATAJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:5678 SASHABAW RD
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3148
Practice Address - Country:US
Practice Address - Phone:248-922-9280
Practice Address - Fax:248-922-9287
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6211111Medicare PIN