Provider Demographics
NPI:1336772540
Name:LEACH, JILLIAN (RN)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:LEACH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:ZURAKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4731 STARBUCK AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3454
Mailing Address - Country:US
Mailing Address - Phone:707-696-7041
Mailing Address - Fax:
Practice Address - Street 1:2225 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5441
Practice Address - Country:US
Practice Address - Phone:707-565-4970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-16
Last Update Date:2020-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95170866163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse