Provider Demographics
NPI:1720540503
Name:WOODWARD, JILL ANN
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:WOODWARD
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 1:8017 SILVER SPRINGS RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-6548
Mailing Address - Country:US
Mailing Address - Phone:260-318-2755
Mailing Address - Fax:
Practice Address - Street 1:7125 S HANNA ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816
Practice Address - Country:US
Practice Address - Phone:260-447-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002395A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant