Provider Demographics
NPI:1477100196
Name:JILLSON, LEAH RENEE
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:RENEE
Last Name:JILLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 CHAPEL FORGE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-1310
Mailing Address - Country:US
Mailing Address - Phone:571-395-1128
Mailing Address - Fax:
Practice Address - Street 1:2028 INDUSTRIAL DR STE B&C
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-2916
Practice Address - Country:US
Practice Address - Phone:410-934-1473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst