Provider Demographics
NPI:1245601491
Name:DAVISSON, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:DAVISSON
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 1:5820 TOWNSHIP ROAD 39 NW
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:OH
Mailing Address - Zip Code:43783-9792
Mailing Address - Country:US
Mailing Address - Phone:740-621-1105
Mailing Address - Fax:
Practice Address - Street 1:5820 TOWNSHIP ROAD 39 NW
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:OH
Practice Address - Zip Code:43783-9792
Practice Address - Country:US
Practice Address - Phone:740-621-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF09151224363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily