Basic Information
| Provider Information | |||||||||
| NPI: | 1457678989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILCOX | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAFFERTY | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 208 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184449135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708429323 | ||||||||
| FaxNumber: | 5708429362 | ||||||||
| Practice Location | |||||||||
| Address1: | 24569 ROUTE 6 | ||||||||
| Address2: | SUITE C | ||||||||
| City: | TOWANDA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188488254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702657688 | ||||||||
| FaxNumber: | 5702657422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.