Provider Demographics
NPI:1275612004
Name:COULTER, JILL E (OT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:COULTER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9756
Mailing Address - Country:US
Mailing Address - Phone:304-757-7293
Mailing Address - Fax:304-757-0574
Practice Address - Street 1:3910 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9756
Practice Address - Country:US
Practice Address - Phone:304-757-7293
Practice Address - Fax:304-757-0574
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV906225X00000X
WV1041100065225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9440132000Medicaid
WV4015922Medicare ID - Type UnspecifiedPROVIDER NUMBER
WV9440132000Medicaid