Provider Demographics
NPI:1508419946
Name:GRANT, JILL ANN (ATC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:GRANT
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 1:75 BROCKWAY RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK VALLEY
Mailing Address - State:CT
Mailing Address - Zip Code:06282-2703
Mailing Address - Country:US
Mailing Address - Phone:860-974-1174
Mailing Address - Fax:
Practice Address - Street 1:75 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK VALLEY
Practice Address - State:CT
Practice Address - Zip Code:06282-2703
Practice Address - Country:US
Practice Address - Phone:860-974-1174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer