Provider Demographics
NPI:1144390394
Name:CONKLE, JILL ALISON (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MISS
First Name:JILL
Middle Name:ALISON
Last Name:CONKLE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3660
Mailing Address - Country:US
Mailing Address - Phone:937-914-7054
Mailing Address - Fax:937-522-7685
Practice Address - Street 1:1141 N MONROE DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-1619
Practice Address - Country:US
Practice Address - Phone:937-372-3638
Practice Address - Fax:937-372-3642
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000288363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50000288OtherOHIO LICENSE
OH50000288OtherOHIO LICENSE