Provider Demographics
NPI:1750727004
Name:WHITLOCK, JILL RENE (FNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:RENE
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 PROFESSIONAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5067
Mailing Address - Country:US
Mailing Address - Phone:618-465-7177
Mailing Address - Fax:618-465-7177
Practice Address - Street 1:131 SAUNDERSVILLE RD
Practice Address - Street 2:SUITE 160
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-8903
Practice Address - Country:US
Practice Address - Phone:615-824-3737
Practice Address - Fax:615-452-8545
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209010355363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209010355OtherILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION
ILF400184943Medicare PIN