Provider Demographics
NPI:1821240177
Name:KOOYOOMJIAN, JILL T (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:T
Last Name:KOOYOOMJIAN
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1 ESSEX CENTER DR.
Mailing Address - Street 2:LAHEY CLINIC
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960
Mailing Address - Country:US
Mailing Address - Phone:781-674-1587
Mailing Address - Fax:781-674-1200
Practice Address - Street 1:1 ESSEX CENTER DRIVE
Practice Address - Street 2:LAHEY NORTHSHORE
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-4711
Practice Address - Country:US
Practice Address - Phone:978-538-4370
Practice Address - Fax:978-538-4708
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2020-06-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA274888163W00000X, 363LX0001X
MARN274888363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110080842AMedicaid
MA000848602Medicare PIN