Healthcare Provider Details

I. General information

NPI: 1194254664
Provider Name (Legal Business Name): JILLIAN A HODGE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22361 OAK RIDGE DR
SHELL KNOB MO
65747-7822
US

IV. Provider business mailing address

22361 OAK RIDGE DR
SHELL KNOB MO
65747
US

V. Phone/Fax

Practice location:
  • Phone: 417-858-3731
  • Fax:
Mailing address:
  • Phone: 855-420-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2004036967
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017021980
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: