Provider Demographics
NPI:1922723642
Name:POLK, JILLIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 SOCIETY ST APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1475
Mailing Address - Country:US
Mailing Address - Phone:803-521-1744
Mailing Address - Fax:
Practice Address - Street 1:79 SOCIETY ST APT A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1475
Practice Address - Country:US
Practice Address - Phone:803-521-1744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4599363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant