Provider Demographics
NPI:1124511944
Name:UZDZINSKI, JILLIAN NICOLE (DO)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:UZDZINSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 ROWAN BLVD APT 620
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2275
Mailing Address - Country:US
Mailing Address - Phone:267-658-0204
Mailing Address - Fax:
Practice Address - Street 1:120 BURRUS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-7812
Practice Address - Country:US
Practice Address - Phone:570-420-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS021404207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program