Provider Demographics
NPI:1104021013
Name:PRIDGEN, JILL DARLENE (PA-C, MS)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:DARLENE
Last Name:PRIDGEN
Suffix:
Gender:F
Credentials:PA-C, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 COUNTY ROAD 2105
Mailing Address - Street 2:
Mailing Address - City:KEMP
Mailing Address - State:TX
Mailing Address - Zip Code:75143-7501
Mailing Address - Country:US
Mailing Address - Phone:903-432-9863
Mailing Address - Fax:
Practice Address - Street 1:604 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MABANK
Practice Address - State:TX
Practice Address - Zip Code:75147-2700
Practice Address - Country:US
Practice Address - Phone:903-887-1073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 01037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS62321Medicare UPIN
TX8B6428Medicare ID - Type Unspecified