Provider Demographics
NPI:1194254664
Name:HODGE, JILLIAN A (NP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:A
Last Name:HODGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22361 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SHELL KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:65747
Mailing Address - Country:US
Mailing Address - Phone:855-420-7900
Mailing Address - Fax:
Practice Address - Street 1:22361 OAK RIDGE DR
Practice Address - Street 2:
Practice Address - City:SHELL KNOB
Practice Address - State:MO
Practice Address - Zip Code:65747-7822
Practice Address - Country:US
Practice Address - Phone:417-858-3731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004036967163W00000X
MO2017021980363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid