Provider Demographics
NPI:1790975423
Name:EGBERT, JILL MARGARET (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARGARET
Last Name:EGBERT
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:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-0026
Mailing Address - Country:US
Mailing Address - Phone:920-294-0189
Mailing Address - Fax:
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI137-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant