Provider Demographics
NPI:1003072174
Name:WHITLEY, JILL MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MICHELLE
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-1903
Mailing Address - Country:US
Mailing Address - Phone:979-821-6300
Mailing Address - Fax:979-823-4545
Practice Address - Street 1:2210 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1903
Practice Address - Country:US
Practice Address - Phone:979-821-6300
Practice Address - Fax:979-823-4545
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202438205Medicaid
TX202438204Medicaid
TX1003072174OtherTRICARE
TX892N51OtherBCBS
TX267848YL1TMedicare PIN
TX267848YK81Medicare PIN