Healthcare Provider Details

I. General information

NPI: 1740028232
Provider Name (Legal Business Name): JILLIAN PURDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 ERDIEL DR
DAYTON OH
45415-3632
US

IV. Provider business mailing address

224 KEELBOAT CT
DAYTON OH
45402-2551
US

V. Phone/Fax

Practice location:
  • Phone: 937-813-8592
  • Fax:
Mailing address:
  • Phone: 419-296-5938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH3204614
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: