Provider Demographics
NPI:1548510662
Name:TARDIF, JILLIAN K (APN-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:K
Last Name:TARDIF
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 WILLIAMSTOWN NEW FREEDOM RD
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1777
Mailing Address - Country:US
Mailing Address - Phone:856-237-8100
Mailing Address - Fax:856-237-8042
Practice Address - Street 1:485 WILLIAMSTOWN NEW FREEDOM RD
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-1777
Practice Address - Country:US
Practice Address - Phone:856-237-8100
Practice Address - Fax:856-237-8042
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00401200363LF0000X
NJ26NR15387300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ123456789OtherPENDING MEDICAL LICENSE