Provider Demographics
NPI:1780302273
Name:WITWICKI, JILLIAN THERESE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:THERESE
Last Name:WITWICKI
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 1:139 HOLTEN ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2669
Mailing Address - Country:US
Mailing Address - Phone:978-854-2342
Mailing Address - Fax:
Practice Address - Street 1:23 CRYSTAL AVE UNIT 2A
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-2425
Practice Address - Country:US
Practice Address - Phone:603-437-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH5048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist