Provider Demographics
NPI:1871226035
Name:EARLY, JILLIAN ALEXANDRA (NP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ALEXANDRA
Last Name:EARLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:POPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-0236
Mailing Address - Country:US
Mailing Address - Phone:260-463-2133
Mailing Address - Fax:260-463-3775
Practice Address - Street 1:2500 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1158
Practice Address - Country:US
Practice Address - Phone:260-463-2133
Practice Address - Fax:260-463-3775
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012801A363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program