Provider Demographics
NPI:1881103323
Name:FORTE, JILLIAN DANIELLE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:DANIELLE
Last Name:FORTE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:20406 42ND AVE APT B
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2613
Mailing Address - Country:US
Mailing Address - Phone:315-264-5033
Mailing Address - Fax:
Practice Address - Street 1:100 MERRICK RD STE 128W
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4821
Practice Address - Country:US
Practice Address - Phone:516-443-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY021298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant