Provider Demographics
NPI:1770851313
Name:DIZON, JILLIAN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:
Last Name:DIZON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4547
Mailing Address - Country:US
Mailing Address - Phone:516-868-7580
Mailing Address - Fax:
Practice Address - Street 1:255 EXECUTIVE DR
Practice Address - Street 2:SUITE LL 105/108
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1718
Practice Address - Country:US
Practice Address - Phone:516-576-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-11
Last Update Date:2011-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63017123225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist