Provider Demographics
NPI:1740739952
Name:BRENNAN, JILL (PTA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8433 GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:MI
Mailing Address - Zip Code:49248-9611
Mailing Address - Country:US
Mailing Address - Phone:517-403-0197
Mailing Address - Fax:
Practice Address - Street 1:900 NE 27TH ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-9548
Practice Address - Country:US
Practice Address - Phone:541-382-0479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA-3955225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant