Provider Demographics
NPI:1164023198
Name:SPADE, JILL MARIE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:SPADE
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 1:58 BROADWAY ST # 25411
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-1056
Mailing Address - Country:US
Mailing Address - Phone:130-461-6689
Mailing Address - Fax:
Practice Address - Street 1:709 W BURKE ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2709
Practice Address - Country:US
Practice Address - Phone:304-901-5172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator