Provider Demographics
NPI:1184818601
Name:BLACK, JILL DIANE (PT, DPT, EDD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:DIANE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT, DPT, EDD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:BLACK
Other - Last Name:LATTANZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 SAVANNAH RD
Mailing Address - Street 2:A-1
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-1550
Mailing Address - Country:US
Mailing Address - Phone:302-644-2530
Mailing Address - Fax:302-644-2556
Practice Address - Street 1:701 SAVANNAH RD
Practice Address - Street 2:A-1
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1550
Practice Address - Country:US
Practice Address - Phone:302-644-2530
Practice Address - Fax:302-644-2556
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10000513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1184818601Medicaid
DE014374S65Medicare PIN