Provider Demographics
NPI:1881206548
Name:DEVINE, JILLIAN M
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:M
Last Name:DEVINE
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 1:546 DELAWARE AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1333
Mailing Address - Country:US
Mailing Address - Phone:630-345-0952
Mailing Address - Fax:
Practice Address - Street 1:546 DELAWARE AVE APT 2S
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1333
Practice Address - Country:US
Practice Address - Phone:630-345-0952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056013716225X00000X
NY023736225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist