Provider Demographics
NPI:1699888032
Name:BALLANTYNE, JILLIAN BIANCA (PHD)
Entity type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:BIANCA
Last Name:BALLANTYNE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:WOMACK ARMY MED. CENTER, DEPT. OF BRAIN INJURY MEDICINE
Mailing Address - Street 2:3908 LONG STREET, BLDG. 3-4303
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310
Mailing Address - Country:US
Mailing Address - Phone:910-907-7709
Mailing Address - Fax:910-643-7041
Practice Address - Street 1:WOMACK ARMY MEDICAL CENTER - DEPT BRAIN INJURY MEDICINE
Practice Address - Street 2:3908 LONG STREET, BLDG. 3-4303
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310
Practice Address - Country:US
Practice Address - Phone:910-907-7709
Practice Address - Fax:910-643-7041
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32912103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist