Provider Demographics
NPI:1730520719
Name:LOURIE, JILLIAN A (MS, OTR/L)
Entity type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:A
Last Name:LOURIE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:BACK MEADOW DR
Mailing Address - City:WEST RUPERT
Mailing Address - State:VT
Mailing Address - Zip Code:05776-0156
Mailing Address - Country:US
Mailing Address - Phone:518-588-4283
Mailing Address - Fax:
Practice Address - Street 1:255 KENT HOLLOW ROAD
Practice Address - Street 2:BACK MEADOW DR
Practice Address - City:WEST RUPERT
Practice Address - State:VT
Practice Address - Zip Code:05776
Practice Address - Country:US
Practice Address - Phone:518-588-4283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT072.0090773225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist