Healthcare Provider Details

I. General information

NPI: 1972893287
Provider Name (Legal Business Name): JILLIAN M SHOLL L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 N 21ST ST
NEWARK OH
43055-2919
US

IV. Provider business mailing address

919 N 21ST ST
NEWARK OH
43055-2919
US

V. Phone/Fax

Practice location:
  • Phone: 740-366-6601
  • Fax: 740-366-6286
Mailing address:
  • Phone: 740-366-6601
  • Fax: 740-366-6286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33018611
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: