Provider Demographics
NPI:1588426845
Name:YOUNG, JILL MARIE (PTA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:814 CHANCE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-1702
Mailing Address - Country:US
Mailing Address - Phone:940-285-0737
Mailing Address - Fax:
Practice Address - Street 1:4601 OLD JACKSBORO HWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-2921
Practice Address - Country:US
Practice Address - Phone:940-343-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2081300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant