Provider Demographics
NPI:1164642823
Name:BANKA, JILL MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MICHELLE
Last Name:BANKA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13608 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-9730
Mailing Address - Country:US
Mailing Address - Phone:616-837-4504
Mailing Address - Fax:
Practice Address - Street 1:25 CONRAN DR
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1366
Practice Address - Country:US
Practice Address - Phone:616-997-6172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236598Medicare ID - Type Unspecified