Provider Demographics
NPI:1033652581
Name:TILLER, JERELYN H (NP)
Entity Type:Individual
Prefix:
First Name:JERELYN
Middle Name:H
Last Name:TILLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 22ND ST S
Mailing Address - Street 2:RIDGE PARK PLACE, SUITE 1000
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-2870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 ALLISON BONNETT MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HUEYTOWN
Practice Address - State:AL
Practice Address - Zip Code:35023-1845
Practice Address - Country:US
Practice Address - Phone:205-744-4410
Practice Address - Fax:205-744-6150
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1139395363LA2200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health