Provider Demographics
NPI:1366164931
Name:SHORT, JILLIAN MICHELE
Entity type:Individual
Prefix:MISS
First Name:JILLIAN
Middle Name:MICHELE
Last Name:SHORT
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 1:402 E 118TH ST APT 6C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-4471
Mailing Address - Country:US
Mailing Address - Phone:916-521-3420
Mailing Address - Fax:
Practice Address - Street 1:2139 ADAM CLAYTON POWELL JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3719
Practice Address - Country:US
Practice Address - Phone:916-521-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program