Provider Demographics
NPI:1790366763
Name:WILLARD, JILLIAN C
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:C
Last Name:WILLARD
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 1:204 BLACK MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6527
Mailing Address - Country:US
Mailing Address - Phone:561-654-6372
Mailing Address - Fax:
Practice Address - Street 1:6633 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3321
Practice Address - Country:US
Practice Address - Phone:704-366-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist