Provider Demographics
NPI:1720322423
Name:BROGAN, JILL
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:
Last Name:BROGAN
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 1:209 ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-3111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:209 ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3111
Practice Address - Country:US
Practice Address - Phone:570-655-2891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015133225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist