Provider Demographics
NPI:1720609894
Name:PERRAULT, JILLIAN BRENNA (ATC)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:BRENNA
Last Name:PERRAULT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ABBEY RD
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-1735
Mailing Address - Country:US
Mailing Address - Phone:607-483-3782
Mailing Address - Fax:
Practice Address - Street 1:5823 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3084
Practice Address - Country:US
Practice Address - Phone:607-483-3782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer