Provider Demographics
NPI:1639681448
Name:DAVENPORT, JILL LEANNE (FNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:LEANNE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4098 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:MI
Mailing Address - Zip Code:48637-9419
Mailing Address - Country:US
Mailing Address - Phone:989-529-0972
Mailing Address - Fax:
Practice Address - Street 1:311 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1088
Practice Address - Country:US
Practice Address - Phone:989-463-4976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704249359NSA17461363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily