Provider Demographics
NPI:1063068963
Name:MADDRA, JILLIAN PAIGE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:PAIGE
Last Name:MADDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CONFEDERACY DR
Mailing Address - Street 2:
Mailing Address - City:PENN LAIRD
Mailing Address - State:VA
Mailing Address - Zip Code:22846-9604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:VA
Practice Address - Zip Code:22812-1511
Practice Address - Country:US
Practice Address - Phone:540-828-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer