Provider Demographics
NPI:1245600121
Name:CHARLES, JILLIAN BLAIR (NP-C)
Entity type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:BLAIR
Last Name:CHARLES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:JILLIAN
Other - Middle Name:BLAIR
Other - Last Name:KAWALEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:A50
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-9606
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:A50
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.18122363LF0000X
OHRN.359991-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse