Provider Demographics
NPI:1710646211
Name:GREVENSTUK, JILLIAN CAROL
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:CAROL
Last Name:GREVENSTUK
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 1:2639 HASELWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-2362
Mailing Address - Country:US
Mailing Address - Phone:806-252-5668
Mailing Address - Fax:
Practice Address - Street 1:2639 HASELWOOD LN
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-2362
Practice Address - Country:US
Practice Address - Phone:806-252-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-12
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1058042363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care MedicineGroup - Single Specialty