Provider Demographics
NPI:1891471413
Name:PEABODY, JILLIAN ROSE
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:ROSE
Last Name:PEABODY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JILLIAN
Other - Middle Name:ROSE
Other - Last Name:KOSSAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37 HAWTHORNE DR APT 408
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-7074
Mailing Address - Country:US
Mailing Address - Phone:603-714-8885
Mailing Address - Fax:
Practice Address - Street 1:1245 ELM ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1308
Practice Address - Country:US
Practice Address - Phone:603-626-9523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist