Provider Demographics
NPI:1114777075
Name:FEOLA, JILLIAN FAITH
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:FAITH
Last Name:FEOLA
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 1:242 GARRETSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1234
Mailing Address - Country:US
Mailing Address - Phone:646-334-3270
Mailing Address - Fax:
Practice Address - Street 1:242 GARRETSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1234
Practice Address - Country:US
Practice Address - Phone:646-334-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1793634242252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency