Healthcare Provider Details

I. General information

NPI: 1427932672
Provider Name (Legal Business Name): JILLIAN MARIE STAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 E STOP 11 RD STE 250
INDIANAPOLIS IN
46237-6343
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1008
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-2270
  • Fax:
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005040A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: