Provider Demographics
NPI:1366847899
Name:MOORE, JILL MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:DORNAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 BOEHM DR
Mailing Address - Street 2:
Mailing Address - City:SHINER
Mailing Address - State:TX
Mailing Address - Zip Code:77984-6288
Mailing Address - Country:US
Mailing Address - Phone:361-594-8301
Mailing Address - Fax:361-594-3033
Practice Address - Street 1:105 BOEHM DR
Practice Address - Street 2:
Practice Address - City:SHINER
Practice Address - State:TX
Practice Address - Zip Code:77984-6288
Practice Address - Country:US
Practice Address - Phone:361-594-8301
Practice Address - Fax:361-594-3033
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113675225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation