Provider Demographics
NPI:1922555648
Name:MISIAK, JILLYAN
Entity Type:Individual
Prefix:
First Name:JILLYAN
Middle Name:
Last Name:MISIAK
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 1:168 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45314-8566
Mailing Address - Country:US
Mailing Address - Phone:734-625-9053
Mailing Address - Fax:
Practice Address - Street 1:1694 PAWNEE DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-4126
Practice Address - Country:US
Practice Address - Phone:937-372-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-11
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker