Provider Demographics
NPI:1144411356
Name:LEARY, JILLIAN MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARIE
Last Name:LEARY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:MARIE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44047
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4047
Mailing Address - Country:US
Mailing Address - Phone:904-376-4083
Mailing Address - Fax:904-391-5075
Practice Address - Street 1:841 PRUDENTIAL DR STE 280
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8350
Practice Address - Country:US
Practice Address - Phone:904-202-8550
Practice Address - Fax:904-393-7808
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9199053363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3085805-00Medicaid
GA509347829AMedicaid
FLAE152YMedicare PIN
FLAE152ZMedicare PIN