Provider Demographics
NPI:1265990147
Name:GILLIS, JENNIFER ANN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:GILLIS
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 1:27A HOBSON AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-2059
Mailing Address - Country:US
Mailing Address - Phone:978-604-2517
Mailing Address - Fax:
Practice Address - Street 1:27A HOBSON AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-2059
Practice Address - Country:US
Practice Address - Phone:978-604-2517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-09
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician