Provider Demographics
NPI:1255629416
Name:JILLSON, KATHERINE (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:JILLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:HIRSCHEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2709 N MAYVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4140
Mailing Address - Country:US
Mailing Address - Phone:612-237-6212
Mailing Address - Fax:
Practice Address - Street 1:2709 N MAYVIEW RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-4140
Practice Address - Country:US
Practice Address - Phone:612-237-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN169919-3163WP0200X
NCJILL-BUGG2363L00000X
NC361768163W00000X
MN271363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400210067OtherMEDICARE PTAN