Provider Demographics
NPI:1679309736
Name:AUSTIN, JILL MATTISON
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MATTISON
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 SCOFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:NY
Mailing Address - Zip Code:13073-9737
Mailing Address - Country:US
Mailing Address - Phone:607-227-8180
Mailing Address - Fax:
Practice Address - Street 1:15 CATHERWOOD RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1071
Practice Address - Country:US
Practice Address - Phone:607-227-4421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY504615225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics