MEDICARE: JILLENE PRUIETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency		OH

General Provider Information

NPI Number	:	1790630861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLENE PRUIETT

Provider Business Mailing Address
First Line	:	11409 GOVERNOR AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-3675
Country	:	US
Telephone Number	:	216-412-1339
Fax Number	:

Provider Business Practice Location Address
First Line	:	11409 GOVERNOR AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-3675
Country	:	US
Telephone Number	:	216-412-1339
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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Directions to “ JILLENE PRUIETT ” Practice Location

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