Provider Demographics
NPI:1871092601
Name:CHAMPION, JILLIAN A (RN)
Entity type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:A
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:A
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4423 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3235
Practice Address - Country:US
Practice Address - Phone:502-749-7909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1141427163WC0200X
KY3017762363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine