Healthcare Provider Details

I. General information

NPI: 1588371322
Provider Name (Legal Business Name): JILL CHRISTINE HENRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL PETERSON

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 OGLETOWN STANTON RD STE 217
NEWARK DE
19713-2074
US

IV. Provider business mailing address

4745 OGLETOWN STANTON RD STE 217
NEWARK DE
19713-2074
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-2410
  • Fax: 302-733-2602
Mailing address:
  • Phone: 302-733-2410
  • Fax: 302-733-2602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0067963
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberLM-0010188
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: