Provider Demographics
NPI:1205317328
Name:CAW, JILLIENNE ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIENNE
Middle Name:ROSE
Last Name:CAW
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 1:196 THOMAS JOHNSON DR STE 120
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4521
Mailing Address - Country:US
Mailing Address - Phone:240-566-3130
Mailing Address - Fax:
Practice Address - Street 1:196 THOMAS JOHNSON DR STE 120
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4521
Practice Address - Country:US
Practice Address - Phone:240-566-3130
Practice Address - Fax:240-566-3131
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant