Provider Demographics
NPI:1851991848
Name:MARCHENKO, JILLIAN ALEXANDRA
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ALEXANDRA
Last Name:MARCHENKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BEACHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-7409
Mailing Address - Country:US
Mailing Address - Phone:203-892-5676
Mailing Address - Fax:
Practice Address - Street 1:43 BEACHLAND AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-7409
Practice Address - Country:US
Practice Address - Phone:203-892-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007459225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist