Provider Demographics
NPI:1013316280
Name:KENT, JILLIAN ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ROSE
Last Name:KENT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:ROSE
Other - Last Name:STEGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD FL 1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-7899
Practice Address - Fax:864-455-5474
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2756363AM0700X, 363A00000X
IL085.005178363A00000X
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3011PAMedicaid