Healthcare Provider Details

I. General information

NPI: 1578926341
Provider Name (Legal Business Name): JILLIAN LEBLANC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 1ST ST N
JACKSONVILLE BEACH FL
32250-6945
US

IV. Provider business mailing address

605 JOHNSTON ST
SAULT SAINTE MARIE MI
49783-2123
US

V. Phone/Fax

Practice location:
  • Phone: 866-581-5038
  • Fax:
Mailing address:
  • Phone: 906-259-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0048342
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: