Provider Demographics
NPI:1437270741
Name:CHANG, JILL (RN)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 WESTERN AVE SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1249
Mailing Address - Country:US
Mailing Address - Phone:330-479-9561
Mailing Address - Fax:
Practice Address - Street 1:2818 LONG AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-4841
Practice Address - Country:US
Practice Address - Phone:330-313-8175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN260053163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2584805Medicaid