Basic Information
| Provider Information | |||||||||
| NPI: | 1952829566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLINE | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | GRACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 N REO STREET | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33609 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 N REO STREET | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133742070 | ||||||||
| FaxNumber: | 8133370937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2017 | ||||||||
| LastUpdateDate: | 09/03/2017 | ||||||||
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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 | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.