Provider Demographics
NPI:1760422588
Name:KILBURN, JACQUELIN KAY (OT)
Entity Type:Individual
Prefix:PROF
First Name:JACQUELIN
Middle Name:KAY
Last Name:KILBURN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:JACQUELIN
Other - Middle Name:KAY
Other - Last Name:MCCONKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:10400 HAMBURG RD
Mailing Address - City:HAMBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48139-0205
Mailing Address - Country:US
Mailing Address - Phone:810-231-9042
Mailing Address - Fax:810-231-9063
Practice Address - Street 1:10400 HAMBURG RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:MI
Practice Address - Zip Code:48139-1204
Practice Address - Country:US
Practice Address - Phone:810-231-9042
Practice Address - Fax:810-231-9063
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XN1300X
MINOT REQUIRED174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN86670001Medicare ID - Type Unspecified