Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 036137824 | IL |
NPI | 1003102773 |
---|---|
Provider Name | Jillian Henry |
First Address | Springfield, IL 62702-4964 |
Second Address | Springfield, IL 62702-4964 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2011 |
Last Update Date | 26/06/2015 |