Provider Demographics
NPI:1245563162
Name:DILLOW ORDONIA, JENESIA ARIELLE
Entity type:Individual
Prefix:
First Name:JENESIA
Middle Name:ARIELLE
Last Name:DILLOW ORDONIA
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 1:3158B HOLLOWAY DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-9030
Mailing Address - Country:US
Mailing Address - Phone:847-275-2696
Mailing Address - Fax:
Practice Address - Street 1:3158B HOLLOWAY DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-9030
Practice Address - Country:US
Practice Address - Phone:847-275-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman