Provider Demographics
NPI:1861988081
Name:TILLMAN, JESSICA LYNN (PHD, MPH, RN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:PHD, MPH, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 BULL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2104
Mailing Address - Country:US
Mailing Address - Phone:803-898-0794
Mailing Address - Fax:
Practice Address - Street 1:2100 BULL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2104
Practice Address - Country:US
Practice Address - Phone:803-898-0794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105587163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse