Provider Demographics
NPI:1811676554
Name:CROSSGROVE, JILLIAN M (BSM, CPM, LDM)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:M
Last Name:CROSSGROVE
Suffix:
Gender:F
Credentials:BSM, CPM, LDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:OR
Mailing Address - Zip Code:97111-9642
Mailing Address - Country:US
Mailing Address - Phone:904-599-9691
Mailing Address - Fax:
Practice Address - Street 1:21861 NE HIDDEN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:OR
Practice Address - Zip Code:97115-9124
Practice Address - Country:US
Practice Address - Phone:503-714-6457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-10226745176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty