Provider Demographics
NPI:1679736235
Name:KING, JILLIAN MOORE (NP-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MOORE
Last Name:KING
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19550 E 39TH ST S
Mailing Address - Street 2:SUITE 210
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-2303
Mailing Address - Country:US
Mailing Address - Phone:816-478-9071
Mailing Address - Fax:
Practice Address - Street 1:19550 E 39TH ST S
Practice Address - Street 2:SUITE 210
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2303
Practice Address - Country:US
Practice Address - Phone:816-478-9071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162789363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA131756716AMedicaid
GA511I500577Medicare PIN