Basic Information
| Provider Information | |||||||||
| NPI: | 1013061043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANTISELL | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT ROAD, NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043647070 | ||||||||
| FaxNumber: | 4703250193 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 STEVE REYNOLDS BLVD | ||||||||
| Address2: | KAISER PERMANENTE GWINNETT COMPREHENSIVE MEDICAL CENTER | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709316012 | ||||||||
| FaxNumber: | 6783775284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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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 | 176B00000X | RN164801 | GA | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 285718185A | 01 | GA | PEACH STATE | OTHER | 285718185A | 05 | GA | MEDICAID | 285718185A | 01 | GA | WELLCARE | OTHER |