Provider Demographics
NPI:1912462649
Name:SCOTT, JILL (OWNER)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E BARTLETT AVE
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9332
Mailing Address - Country:US
Mailing Address - Phone:509-557-6300
Mailing Address - Fax:509-557-6380
Practice Address - Street 1:203 2ND AVE S
Practice Address - Street 2:SUITE 112
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840
Practice Address - Country:US
Practice Address - Phone:509-557-6300
Practice Address - Fax:509-557-6308
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA332BC3200X, 332BX2000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1912462649OtherNPI
WA1912462649Medicaid