Provider Demographics
NPI:1508271354
Name:EHLEN, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:EHLEN
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 1:225 MEMORIAL DR
Mailing Address - Street 2:REHABILITATION DEPARTMENT
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5534
Mailing Address - Fax:920-361-5910
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:REHABILITATION DEPARTMENT
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5534
Practice Address - Fax:920-361-5910
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5509-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI327832OtherNBCOT CERTIFICATION NUMBER
WI5509-26OtherWISCONSIN STATE LICENSE ID