Provider Demographics
NPI:1134335193
Name:DELZEITH, JILL MARIE (COTA)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:MARIE
Last Name:DELZEITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 PAPERMILL XING
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5919
Mailing Address - Country:US
Mailing Address - Phone:260-484-1931
Mailing Address - Fax:
Practice Address - Street 1:1649 SPY RUN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4032
Practice Address - Country:US
Practice Address - Phone:260-422-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001032A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant