Provider Demographics
NPI:1578993630
Name:WALL, JILL (MOTR/L)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34889 GRAPE AVE
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6012
Mailing Address - Country:US
Mailing Address - Phone:909-809-0129
Mailing Address - Fax:909-793-1078
Practice Address - Street 1:205 E STATE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5232
Practice Address - Country:US
Practice Address - Phone:909-793-1078
Practice Address - Fax:909-335-7330
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7786225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics