Provider Demographics
NPI:1770236291
Name:MALCOMB, JILLIAN JARRELL (LOTR)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:JARRELL
Last Name:MALCOMB
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N SPRING DR
Mailing Address - Street 2:
Mailing Address - City:WOODWORTH
Mailing Address - State:LA
Mailing Address - Zip Code:71485-9739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 N SPRING DR
Practice Address - Street 2:
Practice Address - City:WOODWORTH
Practice Address - State:LA
Practice Address - Zip Code:71485-9739
Practice Address - Country:US
Practice Address - Phone:318-792-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200293225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist