Provider Demographics
NPI:1154732469
Name:POPOWSKI, JILL (PT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:POPOWSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6149 SW COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1307
Mailing Address - Country:US
Mailing Address - Phone:541-223-6020
Mailing Address - Fax:
Practice Address - Street 1:305 SW C AVE STE 1
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4400
Practice Address - Country:US
Practice Address - Phone:541-223-6020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2813174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist