Provider Demographics
NPI:1477061430
Name:MADEY, JILL GROSSO (LAC)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:GROSSO
Last Name:MADEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 ASTON FOREST LN
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1606
Mailing Address - Country:US
Mailing Address - Phone:703-303-5457
Mailing Address - Fax:
Practice Address - Street 1:292 ASTON FOREST LN
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-1606
Practice Address - Country:US
Practice Address - Phone:703-303-5457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02479171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist