Provider Demographics
NPI:1114512191
Name:MOGERMAN, JILLIAN LEE (NP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEE
Last Name:MOGERMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5656 W US HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2454
Mailing Address - Country:US
Mailing Address - Phone:231-316-1017
Mailing Address - Fax:
Practice Address - Street 1:5656 W US HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2454
Practice Address - Country:US
Practice Address - Phone:231-316-1017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307282363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner