Provider Demographics
NPI:1497149306
Name:BLACKWELL, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 BRIARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1404 BRIARWOOD CT
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-3833
Practice Address - Country:US
Practice Address - Phone:203-525-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-28
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist