Basic Information
| Provider Information | |||||||||
| NPI: | 1750727004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITLOCK | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | RENE | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 PROFESSIONAL DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184657177 | ||||||||
| FaxNumber: | 6184657177 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 SAUNDERSVILLE RD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370758903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158243737 | ||||||||
| FaxNumber: | 6154528545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209010355 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209010355 | 01 | IL | ILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION | OTHER |