Provider Demographics
NPI:1871795278
Name:MATTHEWS, JILL SUSAN (RNC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:SUSAN
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25528 KNAPP LN
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48134-0715
Mailing Address - Country:US
Mailing Address - Phone:734-789-9914
Mailing Address - Fax:313-389-2956
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7705
Practice Address - Fax:734-785-7734
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704168922163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent