Provider Demographics
NPI:1356910327
Name:DEWITT, JILL MARIE CHRISTINE (LVN)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE CHRISTINE
Last Name:DEWITT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE CHRISTINE
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LVN
Mailing Address - Street 1:110 DELLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-2014
Mailing Address - Country:US
Mailing Address - Phone:951-660-4679
Mailing Address - Fax:
Practice Address - Street 1:110 DELLWOOD CT
Practice Address - Street 2:
Practice Address - City:LA MARQUE
Practice Address - State:TX
Practice Address - Zip Code:77568-2014
Practice Address - Country:US
Practice Address - Phone:051-660-4679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1012876164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse