Provider Demographics
NPI:1639351448
Name:CLARK, JILL PAGE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:PAGE
Last Name:CLARK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 WOODLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-5760
Mailing Address - Country:US
Mailing Address - Phone:919-773-0120
Mailing Address - Fax:
Practice Address - Street 1:1500 WOODLINE DRIVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-5760
Practice Address - Country:US
Practice Address - Phone:919-773-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4777224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant