Provider Demographics
NPI:1629359310
Name:MUMBACH, JILL KRISTEN (OT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:KRISTEN
Last Name:MUMBACH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:KRISTEN
Other - Last Name:MUMBACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT
Mailing Address - Street 1:12970 VAN SLYKE RD
Mailing Address - Street 2:
Mailing Address - City:EAST CONCORD
Mailing Address - State:NY
Mailing Address - Zip Code:14055-9796
Mailing Address - Country:US
Mailing Address - Phone:716-592-9829
Mailing Address - Fax:
Practice Address - Street 1:12970 VAN SLYKE RD
Practice Address - Street 2:
Practice Address - City:EAST CONCORD
Practice Address - State:NY
Practice Address - Zip Code:14055-9796
Practice Address - Country:US
Practice Address - Phone:716-592-9829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005810-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics