Provider Demographics
NPI:1588683940
Name:KIILSGAARD, JAN (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:
Last Name:KIILSGAARD
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 HIGH SCHOOL DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2670
Mailing Address - Country:US
Mailing Address - Phone:870-234-3757
Mailing Address - Fax:
Practice Address - Street 1:100 E. UNIVERSITY
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71754
Practice Address - Country:US
Practice Address - Phone:870-235-4161
Practice Address - Fax:870-235-4988
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT2972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer