Provider Demographics
NPI:1326607490
Name:MARRA, JILLIAN YOUNG (FNP-C)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:YOUNG
Last Name:MARRA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 BARBEN AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4504
Mailing Address - Country:US
Mailing Address - Phone:315-314-1579
Mailing Address - Fax:
Practice Address - Street 1:53-59 PUBLIC SQ STE 301
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2674
Practice Address - Country:US
Practice Address - Phone:315-782-2141
Practice Address - Fax:315-782-5123
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY673632163W00000X
NYF344601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse