Provider Demographics
NPI:1437168887
Name:WILSON, JILL MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-6216
Mailing Address - Country:US
Mailing Address - Phone:360-533-3853
Mailing Address - Fax:360-533-3310
Practice Address - Street 1:220 W 1ST ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6216
Practice Address - Country:US
Practice Address - Phone:360-533-3853
Practice Address - Fax:360-533-3310
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2354WIOtherREGENCE BLUE SHIELD
WA8333452Medicaid
WA0150618OtherLABOR AND INDUSTRIES
WA2354WIOtherREGENCE BLUE SHIELD