Provider Demographics
NPI:1366953952
Name:RICARD, JILLIAN L
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:L
Last Name:RICARD
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 1:926 SE BELFAST AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3914
Mailing Address - Country:US
Mailing Address - Phone:772-924-5773
Mailing Address - Fax:
Practice Address - Street 1:926 SE BELFAST AVENUE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-3498
Practice Address - Country:US
Practice Address - Phone:772-924-5773
Practice Address - Fax:772-924-5773
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
FLCBC035798171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCBC035798OtherCERTIFIED BUILDING CONTRACTOR
FL$$$$$$$$$Medicaid