Provider Demographics
NPI:1891941431
Name:BLACK, JILLENE MCMINN (OTR)
Entity type:Individual
Prefix:
First Name:JILLENE
Middle Name:MCMINN
Last Name:BLACK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 E 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1301
Mailing Address - Country:US
Mailing Address - Phone:303-466-6308
Mailing Address - Fax:303-466-1224
Practice Address - Street 1:1145 E 13TH AVE
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1301
Practice Address - Country:US
Practice Address - Phone:303-466-6308
Practice Address - Fax:303-466-1224
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAA439869225X00000X
CO0278321225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist