Provider Demographics
NPI:1972203750
Name:DULLI, JACILYNN OLIVIA (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JACILYNN
Middle Name:OLIVIA
Last Name:DULLI
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 VALLEY DR APT 1
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-9012
Mailing Address - Country:US
Mailing Address - Phone:479-393-0378
Mailing Address - Fax:
Practice Address - Street 1:2911 LONGVIEW DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5911
Practice Address - Country:US
Practice Address - Phone:870-336-0238
Practice Address - Fax:870-336-0239
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant