Provider Demographics
NPI:1669066312
Name:CONRAD, JILLIAN
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:CONRAD
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 1:768 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-5833
Mailing Address - Country:US
Mailing Address - Phone:360-348-0397
Mailing Address - Fax:
Practice Address - Street 1:BOB CHISHOLM CENTER
Practice Address - Street 2:1225 AVE. A
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138
Practice Address - Country:US
Practice Address - Phone:503-738-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR174H00000XMedicaid