Healthcare Provider Details

I. General information

NPI: 1275445652
Provider Name (Legal Business Name): JESSICA GILLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 VILLAGE GRANDE DR
PONTE VEDRA FL
32081-0095
US

IV. Provider business mailing address

361 VILLAGE GRANDE DR
PONTE VEDRA FL
32081-0095
US

V. Phone/Fax

Practice location:
  • Phone: 925-768-2100
  • Fax:
Mailing address:
  • Phone: 925-768-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: