Provider Demographics
NPI:1568738664
Name:ILLERA, JACQUELINE V (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:V
Last Name:ILLERA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3419
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10163-3419
Mailing Address - Country:US
Mailing Address - Phone:415-424-9905
Mailing Address - Fax:
Practice Address - Street 1:331 E 91ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5301
Practice Address - Country:US
Practice Address - Phone:415-424-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010033-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist