Provider Demographics
NPI:1821392457
Name:TRAVIS, JILLIAN MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARIE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 W SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-1554
Mailing Address - Country:US
Mailing Address - Phone:712-246-2180
Mailing Address - Fax:712-246-1683
Practice Address - Street 1:1213 W NISHNA RD
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-2115
Practice Address - Country:US
Practice Address - Phone:712-246-2180
Practice Address - Fax:712-246-1683
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA55871223G0001X
IA2062124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0062240Medicaid
IA1306926407OtherNPI