Provider Demographics
NPI:1407946007
Name:ERICKSON, JILL A (PA)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:A
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:JILL
Other - Middle Name:A
Other - Last Name:GOLEBIEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 58108
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-0108
Mailing Address - Country:US
Mailing Address - Phone:801-581-3998
Mailing Address - Fax:
Practice Address - Street 1:590 WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1200
Practice Address - Country:US
Practice Address - Phone:801-587-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT377159-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant