Healthcare Provider Details

I. General information

NPI: 1528874666
Provider Name (Legal Business Name): JENNIFER KILLGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28170 N MAIN ST STE C
DAPHNE AL
36526-7010
US

IV. Provider business mailing address

28170 N MAIN ST STE C
DAPHNE AL
36526-7010
US

V. Phone/Fax

Practice location:
  • Phone: 251-616-4201
  • Fax:
Mailing address:
  • Phone: 251-616-4201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3263
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: