Provider Demographics
NPI:1750569851
Name:GILLILAND, JACKIE CAROLE (RN BSN IBCLC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:CAROLE
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:RN BSN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8237 NW STONEBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-4127
Mailing Address - Country:US
Mailing Address - Phone:580-536-3743
Mailing Address - Fax:
Practice Address - Street 1:8237 NW STONEBRIDGE CT
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-4127
Practice Address - Country:US
Practice Address - Phone:580-536-3743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0027885163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749570SMedicaid