Provider Demographics
NPI:1124235908
Name:WHATLEY, JILL (PTA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WHATLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5299 CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-3143
Mailing Address - Country:US
Mailing Address - Phone:229-559-5819
Mailing Address - Fax:
Practice Address - Street 1:2109 N PATTERSON ST
Practice Address - Street 2:STE A
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2946
Practice Address - Country:US
Practice Address - Phone:229-247-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA000952225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant