Provider Demographics
NPI:1154711570
Name:GILLIAND, JONATHAN ROBERT
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:GILLIAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1143
Mailing Address - Country:US
Mailing Address - Phone:910-568-7627
Mailing Address - Fax:
Practice Address - Street 1:330 PONDEROSA DR
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1143
Practice Address - Country:US
Practice Address - Phone:910-568-7627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-24
Last Update Date:2015-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner