Healthcare Provider Details

I. General information

NPI: 1972269165
Provider Name (Legal Business Name): JILLIAN LEE RIES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 E BROADWAY ST
MOUNT PLEASANT MI
48858-2933
US

IV. Provider business mailing address

607 RIVERVIEW CT
GLADWIN MI
48624-1956
US

V. Phone/Fax

Practice location:
  • Phone: 989-854-8334
  • Fax:
Mailing address:
  • Phone: 989-329-4663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: