Provider Demographics
NPI:1447216999
Name:LEBOURDAIS, JILL ANNE (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANNE
Last Name:LEBOURDAIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 BAY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2433
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:989-791-1392
Practice Address - Street 1:4905 BERL DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2801
Practice Address - Country:US
Practice Address - Phone:989-996-0566
Practice Address - Fax:989-583-6915
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003221363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5731192OtherBCBSM
MI0992118OtherHEALTH PLUS
MI4472609Medicaid
MI26401OtherHEALTH PLAN OF MI
P00088330OtherRAILROAD MEDICARE
MI5731192OtherBCBSM
MI4472609Medicaid
MIMI5598002Medicare PIN