Provider Demographics
NPI:1942520796
Name:BRENNAN, JILLIAN LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEIGH
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1601
Mailing Address - Country:US
Mailing Address - Phone:802-264-8158
Mailing Address - Fax:802-860-4313
Practice Address - Street 1:617 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1601
Practice Address - Country:US
Practice Address - Phone:802-264-8158
Practice Address - Fax:802-860-4313
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420012666207Q00000X
VT042.0012666208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1022382Medicaid
VTP01338829OtherRAILROAD MEDICARE
VT1022382Medicaid