Basic Information
| Provider Information | |||||||||
| NPI: | 1164678017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERIK | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3164 US HIGHWAY 70 | ||||||||
| Address2: | |||||||||
| City: | BLACK MOUNTAIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287116302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286694505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3164 US HIGHWAY 70 | ||||||||
| Address2: | |||||||||
| City: | BLACK MOUNTAIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287116302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286694505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 08/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP2805012 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | MK2205931 | 01 | NC | DEA | OTHER |