Provider Demographics
NPI:1942747274
Name:PAVESICH, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:PAVESICH
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 1:1715 MINTER BLUE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30454-1228
Mailing Address - Country:US
Mailing Address - Phone:478-697-2665
Mailing Address - Fax:
Practice Address - Street 1:2400 BELLEVUE RD
Practice Address - Street 2:SUITE 26
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2885
Practice Address - Country:US
Practice Address - Phone:478-272-8266
Practice Address - Fax:478-272-7552
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN164363363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily