Provider Demographics
NPI:1093368128
Name:GILLIS, JESSICA (OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GILLIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 PARAGON DR APT E
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6927
Mailing Address - Country:US
Mailing Address - Phone:508-631-5404
Mailing Address - Fax:
Practice Address - Street 1:5820 FLINTRIDGE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1883
Practice Address - Country:US
Practice Address - Phone:508-631-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0005685225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist