Provider Demographics
NPI:1972709962
Name:GIBBONS ROSE, JILLIAN EILEEN (OTR/L)
Entity type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:EILEEN
Last Name:GIBBONS ROSE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:EILEEN
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:5970 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN LANE
Mailing Address - State:PA
Mailing Address - Zip Code:18054-2285
Mailing Address - Country:US
Mailing Address - Phone:215-219-3110
Mailing Address - Fax:
Practice Address - Street 1:3975 CONSHOHOCKEN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-5426
Practice Address - Country:US
Practice Address - Phone:215-879-1000
Practice Address - Fax:215-879-3912
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010061225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020254040001Medicaid