Healthcare Provider Details

I. General information

NPI: 1306563036
Provider Name (Legal Business Name): JESSICA GILLILAND SW-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 PARK AVE
IRONTON OH
45638-1502
US

IV. Provider business mailing address

PO BOX 108
IRONTON OH
45638-0108
US

V. Phone/Fax

Practice location:
  • Phone: 740-532-1613
  • Fax: 740-879-0599
Mailing address:
  • Phone: 740-532-1613
  • Fax: 740-879-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2202608-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: