Provider Demographics
NPI:1659794618
Name:CULLISON, JILLIAN (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:CULLISON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:WHITLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:75 CLAREMONT ST STE H
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3500
Mailing Address - Country:US
Mailing Address - Phone:406-752-7406
Mailing Address - Fax:406-752-7544
Practice Address - Street 1:75 CLAREMONT ST STE H
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3500
Practice Address - Country:US
Practice Address - Phone:406-752-7406
Practice Address - Fax:406-752-7544
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT107835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0097997Medicaid