Provider Demographics
NPI:1609940956
Name:MALOUF, JILLIAN
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:MALOUF
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 1:5193 BORCH ST N
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-9036
Mailing Address - Country:US
Mailing Address - Phone:907-617-0467
Mailing Address - Fax:
Practice Address - Street 1:5193 BORCH ST N
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-9036
Practice Address - Country:US
Practice Address - Phone:907-617-0467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK882225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOT5664Medicaid