Provider Demographics
NPI:1366767840
Name:SHEA, JILL P
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:P
Last Name:SHEA
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 1:541 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-4203
Mailing Address - Country:US
Mailing Address - Phone:203-876-7643
Mailing Address - Fax:
Practice Address - Street 1:541 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-4203
Practice Address - Country:US
Practice Address - Phone:203-876-7643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8660183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist