Provider Demographics
NPI:1194237552
Name:OTT, JILLAINE LOUISE (OTA)
Entity type:Individual
Prefix:
First Name:JILLAINE
Middle Name:LOUISE
Last Name:OTT
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6155 MINERAL POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4457
Mailing Address - Country:US
Mailing Address - Phone:608-230-4443
Mailing Address - Fax:
Practice Address - Street 1:6155 MINERAL POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4457
Practice Address - Country:US
Practice Address - Phone:608-230-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1859-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI$$$$$$$$$OtherNPI
WI$$$$$$$$$Medicaid