Provider Demographics
NPI:1407352065
Name:THAYER, JILLIAN LEE (MD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEE
Last Name:THAYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 PLAZA WAY FL 5
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-2718
Mailing Address - Country:US
Mailing Address - Phone:509-221-6450
Mailing Address - Fax:509-221-6511
Practice Address - Street 1:3730 PLAZA WAY FL 5
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-2718
Practice Address - Country:US
Practice Address - Phone:267-441-4583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61328250208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery