Healthcare Provider Details

I. General information

NPI: 1538914767
Provider Name (Legal Business Name): JILLIAN E HURT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 04/22/2024
Certification Date: 04/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 S 13TH ST
MATTOON IL
61938-5710
US

IV. Provider business mailing address

1012 S 13TH ST
MATTOON IL
61938-5710
US

V. Phone/Fax

Practice location:
  • Phone: 217-821-3844
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: