Basic Information
Provider Information | |||||||||
NPI: | 1346449584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHILDRES | ||||||||
FirstName: | JILLIAN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 917770 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328910001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139742201 | ||||||||
FaxNumber: | 8139742812 | ||||||||
Practice Location | |||||||||
Address1: | 13101 BRUCE B DOWNS BLVD | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336123803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139741189 | ||||||||
FaxNumber: | 8135581343 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2007 | ||||||||
LastUpdateDate: | 02/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |   | 103TS0200X | PY8272 | FL | Y |   | Behavioral Health & Social Service Providers | Psychologist | School | 103T00000X | PY8272 | FL | N |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 593P1 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |