Provider Demographics
NPI:1336884998
Name:WALSH, JILLIAN MARZEL
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARZEL
Last Name:WALSH
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 1:9869 GARDEN WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-0199
Mailing Address - Country:US
Mailing Address - Phone:708-828-2762
Mailing Address - Fax:
Practice Address - Street 1:10700 PARK PL
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8666
Practice Address - Country:US
Practice Address - Phone:219-247-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002180A224ZF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & Swallowing