Provider Demographics
NPI:1407832462
Name:HARBISON, JILL PAGE (CDE)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:PAGE
Last Name:HARBISON
Suffix:
Gender:F
Credentials:CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E CENTRAL AVE
Mailing Address - Street 2:BOND CLINIC , P.A.
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880
Mailing Address - Country:US
Mailing Address - Phone:863-293-1191
Mailing Address - Fax:863-293-3635
Practice Address - Street 1:199 AVE. B., N.W.
Practice Address - Street 2:BOND CLINIC , P.A.
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-293-1191
Practice Address - Fax:863-508-2213
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND1986133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8908869-00Medicaid