Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 209595 | TX |
NPI | 1013314707 |
---|---|
Provider Name | Jennifer Gilliam |
First Address | Corsicana, TX 75110-4562 |
Second Address | Corsicana, TX 75110-4562 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/11/2014 |
Last Update Date | 25/11/2014 |