Provider Demographics
NPI:1710367784
Name:TILLEY, JENIFER (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:TILLEY
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 TILLEY LANE
Mailing Address - Street 2:
Mailing Address - City:HOOSICK FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 WARREN ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4525
Practice Address - Country:US
Practice Address - Phone:518-793-5163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019080-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist