Provider Demographics
NPI:1194809806
Name:JESURUM, JILL T (ARNP, PHD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:T
Last Name:JESURUM
Suffix:
Gender:F
Credentials:ARNP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741515
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-1515
Mailing Address - Country:US
Mailing Address - Phone:206-223-6198
Mailing Address - Fax:206-341-0591
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6198
Practice Address - Fax:206-341-0591
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005750363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily