Provider Demographics
NPI:1386354363
Name:VINE, JILLIAN E (CTRS)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:E
Last Name:VINE
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 UPPER DELEVAN AVE
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-3267
Mailing Address - Country:US
Mailing Address - Phone:607-684-7506
Mailing Address - Fax:
Practice Address - Street 1:76 VETERANS AVE BLDG 92
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-0810
Practice Address - Country:US
Practice Address - Phone:607-664-4694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist