Provider Demographics
NPI:1003475674
Name:FIELDS, JILLIAN NICOLE (LAT,ATC)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:FIELDS
Suffix:
Gender:F
Credentials:LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 SHARLOH LOOP
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-7700
Mailing Address - Country:US
Mailing Address - Phone:636-352-7983
Mailing Address - Fax:
Practice Address - Street 1:1025 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3536
Practice Address - Country:US
Practice Address - Phone:636-352-7983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND809-182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND809-18OtherNORTH DAKOTA BOARD OF ATHLETIC TRAINERS