Healthcare Provider Details

I. General information

NPI: 1396595617
Provider Name (Legal Business Name): JILLIAN IRENE HORNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 FINNEY BLVD
MALONE NY
12953-1067
US

IV. Provider business mailing address

PO BOX 608
MALONE NY
12953-0608
US

V. Phone/Fax

Practice location:
  • Phone: 518-481-8160
  • Fax: 518-481-8161
Mailing address:
  • Phone: 518-483-1251
  • Fax: 518-483-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: