Provider Demographics
NPI:1902144058
Name:BROYLES, JILL J (COTA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:J
Last Name:BROYLES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25061 FAT BOB TRL
Mailing Address - Street 2:
Mailing Address - City:SHELL KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:65747-7889
Mailing Address - Country:US
Mailing Address - Phone:316-204-0607
Mailing Address - Fax:
Practice Address - Street 1:23 PARKCLIFF DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY ISLAND
Practice Address - State:AR
Practice Address - Zip Code:72631-8045
Practice Address - Country:US
Practice Address - Phone:479-363-6422
Practice Address - Fax:479-363-6763
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021006128224Z00000X
KS1800833224Z00000X
KS3786376G00000X
AROT-A1905224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No376G00000XNursing Service Related ProvidersNursing Home Administrator