Provider Demographics
NPI:1184749608
Name:FENNELLY, JILL ELIZABETH (PT)
Entity type:Individual
Prefix:MISS
First Name:JILL
Middle Name:ELIZABETH
Last Name:FENNELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 GREEN LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2620
Mailing Address - Country:US
Mailing Address - Phone:610-888-9684
Mailing Address - Fax:
Practice Address - Street 1:1104 WELSH RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3730
Practice Address - Country:US
Practice Address - Phone:215-676-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0153062251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics