=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134536840
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER JOAN TILLMAN NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2014
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30000 E RIVER RD
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-931-3440
-----------------------------------------------------
Fax | 419-661-4020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 ROSEHILL RD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49202-1762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-212-2008
-----------------------------------------------------
Fax | 517-212-9023
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.15986
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 15986
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------