Basic Information
| Provider Information | |||||||||
| NPI: | 1295876449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261871615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043757992 | ||||||||
| FaxNumber: | 3043753762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34.008561 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2137 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2782387 | 05 | OH | MEDICAID | 3810009940 | 05 | WV | MEDICAID |