Provider Demographics
NPI:1093975039
Name:FERGUSON, JILL ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:ANNE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731280
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1280
Mailing Address - Country:US
Mailing Address - Phone:318-841-9526
Mailing Address - Fax:318-841-9551
Practice Address - Street 1:2915 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-4327
Practice Address - Country:US
Practice Address - Phone:318-621-8820
Practice Address - Fax:318-212-4189
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013817A207ZP0102X
LA205414207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.205414OtherLA - STATE LICENSE MD
LA12373627OtherCAQH PROVIDER ID
LAP01099769OtherRR MEDICARE
LA2302086Medicaid
LAP01099769OtherRR MEDICARE