Provider Demographics
NPI:1538708524
Name:GILLILAND, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:GILLILAND
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 1:204 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEON
Mailing Address - State:IA
Mailing Address - Zip Code:50144-1450
Mailing Address - Country:US
Mailing Address - Phone:641-446-4136
Mailing Address - Fax:
Practice Address - Street 1:204 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEON
Practice Address - State:IA
Practice Address - Zip Code:50144-1450
Practice Address - Country:US
Practice Address - Phone:641-446-4136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist