Provider Demographics
NPI:1992936009
Name:PITTARD, JAN ELLEN (OT)
Entity type:Individual
Prefix:MS
First Name:JAN
Middle Name:ELLEN
Last Name:PITTARD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5128
Mailing Address - Country:US
Mailing Address - Phone:817-680-0015
Mailing Address - Fax:
Practice Address - Street 1:605 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-1263
Practice Address - Country:US
Practice Address - Phone:940-627-5444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109612225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist