Healthcare Provider Details

I. General information

NPI: 1215651419
Provider Name (Legal Business Name): JILLIAN KOPCIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W FAYETTE ST STE 300
BALTIMORE MD
21201-1756
US

IV. Provider business mailing address

604 S LAKEWOOD AVE
BALTIMORE MD
21224-3824
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-2781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: