Provider Demographics
NPI:1801393558
Name:CHAMPAGNE, JILLIAN (DPT, PT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CREDIT UNION WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:22 MILL ST STE 406
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4744
Practice Address - Country:US
Practice Address - Phone:781-646-8440
Practice Address - Fax:781-643-7542
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA22080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist