Provider Demographics
NPI:1346372893
Name:ROGACKI, JILL ELLEN (ATC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ELLEN
Last Name:ROGACKI
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 MAJESTIC DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-1164
Mailing Address - Country:US
Mailing Address - Phone:734-347-6853
Mailing Address - Fax:419-335-1921
Practice Address - Street 1:138 E ELM ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1457
Practice Address - Country:US
Practice Address - Phone:419-335-1919
Practice Address - Fax:419-335-1921
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH22002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer