Healthcare Provider Details

I. General information

NPI: 1104415884
Provider Name (Legal Business Name): JILLIAN O'MELIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DAWN HL
BRISTOL RI
02809-3903
US

IV. Provider business mailing address

PO BOX 7411009
CHICAGO IL
60674-3009
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 872-231-3162
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01317
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8097
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: