Provider Demographics
NPI:1699894360
Name:GABRIELSEN, JILL A (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:GABRIELSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 ALLENS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5010
Mailing Address - Country:US
Mailing Address - Phone:401-444-0400
Mailing Address - Fax:401-444-0468
Practice Address - Street 1:355 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:401-444-0570
Practice Address - Fax:401-444-0427
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015709208000000X
RIMD15039208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME329070099Medicaid