Healthcare Provider Details

I. General information

NPI: 1821814146
Provider Name (Legal Business Name): JILLIAN RAE FOERTSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TAMPA GENERAL CIR
TAMPA FL
33606-3571
US

IV. Provider business mailing address

10213 COOL WATERLILY AVE
RIVERVIEW FL
33578-4380
US

V. Phone/Fax

Practice location:
  • Phone: 813-844-0000
  • Fax:
Mailing address:
  • Phone: 631-487-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9522965
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number11037463
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11037463
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: