Basic Information
| Provider Information | |||||||||
| NPI: | 1932660024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16720 HICKORY CREST DR | ||||||||
| Address2: | |||||||||
| City: | WILDWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630115501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362223892 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15425 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630113077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362206969 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2019 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2012028527 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.