Provider Demographics
NPI:1104287457
Name:RUSSELL, JILLIAN E
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:E
Last Name:RUSSELL
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 1:2415 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-2618
Mailing Address - Country:US
Mailing Address - Phone:352-732-5365
Mailing Address - Fax:352-690-6607
Practice Address - Street 1:2415 SE 17TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-2618
Practice Address - Country:US
Practice Address - Phone:352-732-5365
Practice Address - Fax:352-690-6607
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3414572363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner