Provider Demographics
NPI:1841882354
Name:WADDELL, JILLIAN NICOLE
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:WADDELL
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 1:5424 GEROME PL
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-7900
Mailing Address - Country:US
Mailing Address - Phone:910-685-6314
Mailing Address - Fax:
Practice Address - Street 1:5424 GEROME PL
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-7900
Practice Address - Country:US
Practice Address - Phone:910-685-6314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency