Provider Demographics
NPI:1194580548
Name:KODGER, JILLIAN
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:KODGER
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 1:12039 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1787
Mailing Address - Country:US
Mailing Address - Phone:330-591-7522
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program