Provider Demographics
NPI:1649057688
Name:MOFFETT, JILLIAN ROSE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ROSE
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:ROSE
Other - Last Name:BALKENHOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5134 TOWN PL
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-1758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 PARK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1110
Practice Address - Country:US
Practice Address - Phone:203-688-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT153014163W00000X, 163WP0218X
CA95328625163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0218XNursing Service ProvidersRegistered NursePediatric Oncology
No163W00000XNursing Service ProvidersRegistered Nurse