Provider Demographics
NPI:1295941771
Name:EDLIN, JILL M
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:EDLIN
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 1:315 ROSEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-8128
Mailing Address - Country:US
Mailing Address - Phone:270-699-2776
Mailing Address - Fax:270-699-2780
Practice Address - Street 1:315 ROSEWOOD ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-8128
Practice Address - Country:US
Practice Address - Phone:270-699-2776
Practice Address - Fax:270-699-2780
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3058225X00000X
KY134718225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1649OtherFIRST STEPS PROVIDER
KY2245OtherFIRST STEPS PROVIDER