Healthcare Provider Details

I. General information

NPI: 1144810235
Provider Name (Legal Business Name): JILL MICHELLE MORAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7795 117TH ST
SEMINOLE FL
33772-5223
US

IV. Provider business mailing address

7795 117TH ST
SEMINOLE FL
33772-5223
US

V. Phone/Fax

Practice location:
  • Phone: 727-418-2120
  • Fax: 352-820-4133
Mailing address:
  • Phone: 727-418-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11020432
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: