Provider Demographics
NPI:1962272567
Name:GAY, JILLIAN MARISSA
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARISSA
Last Name:GAY
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 1:2270 S BLOCK RD
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-9751
Mailing Address - Country:US
Mailing Address - Phone:989-823-4956
Mailing Address - Fax:
Practice Address - Street 1:526 W GENESEE ST STE 4
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1357
Practice Address - Country:US
Practice Address - Phone:989-652-2577
Practice Address - Fax:989-652-4776
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501001540225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist