Provider Demographics
NPI:1164451845
Name:SHEORN, JILL S (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:S
Last Name:SHEORN
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 1:116 STANDARD WAREHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9670
Mailing Address - Country:US
Mailing Address - Phone:803-438-6023
Mailing Address - Fax:803-438-3671
Practice Address - Street 1:116 STANDARD WAREHOUSE RD
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9670
Practice Address - Country:US
Practice Address - Phone:803-438-6023
Practice Address - Fax:803-438-3671
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1890363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC264412Medicaid
SC264412Medicaid
SCAA5687E151Medicare PIN