Provider Demographics
NPI:1780928002
Name:DRAGOONE, JILLANN MARIE (COTA)
Entity type:Individual
Prefix:MRS
First Name:JILLANN
Middle Name:MARIE
Last Name:DRAGOONE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:DRAGOONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:603 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5847
Mailing Address - Country:US
Mailing Address - Phone:678-880-7580
Mailing Address - Fax:
Practice Address - Street 1:603 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5847
Practice Address - Country:US
Practice Address - Phone:678-880-7580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001092224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant