Provider Demographics
NPI:1205062908
Name:COOK, JILL SCHOLLENBERGER (PTA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:SCHOLLENBERGER
Last Name:COOK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 N DIXIE FWY
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6220
Mailing Address - Country:US
Mailing Address - Phone:386-426-7885
Mailing Address - Fax:866-239-9013
Practice Address - Street 1:916 N DIXIE FWY
Practice Address - Street 2:STE. 1700
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6220
Practice Address - Country:US
Practice Address - Phone:386-426-7885
Practice Address - Fax:866-239-9013
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24110225200000X
GA002403225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1205062908Medicare UPIN