Provider Demographics
NPI:1487880134
Name:LACK, JILL (OT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LACK
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 1:1215 HOWARD LN
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-2705
Mailing Address - Country:US
Mailing Address - Phone:713-213-9060
Mailing Address - Fax:
Practice Address - Street 1:1215 HOWARD LN
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2705
Practice Address - Country:US
Practice Address - Phone:713-213-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108235225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist