Provider Demographics
NPI:1013314707
Name:GILLIAM, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GILLIAM
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 1:500 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-4562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-4562
Practice Address - Country:US
Practice Address - Phone:903-870-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209595224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant