Provider Demographics
NPI:1952991812
Name:HILLIS, JACLYN KELLY
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:KELLY
Last Name:HILLIS
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 1:12600 LONG BRANCH CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-3164
Mailing Address - Country:US
Mailing Address - Phone:804-627-1780
Mailing Address - Fax:
Practice Address - Street 1:12600 LONG BRANCH CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-3164
Practice Address - Country:US
Practice Address - Phone:804-627-1780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer