Provider Demographics
NPI:1093332439
Name:TILLMAN, JENNIFER ELISHA (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELISHA
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELISHA
Other - Last Name:TILLMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CASE MANAGER
Mailing Address - Street 1:304 NW 5TH ST PLAZA 300
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34972
Mailing Address - Country:US
Mailing Address - Phone:863-357-8268
Mailing Address - Fax:863-357-8269
Practice Address - Street 1:304 NW 5TH ST PLAZA 300
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972
Practice Address - Country:US
Practice Address - Phone:863-357-8268
Practice Address - Fax:863-357-8269
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator