Provider Demographics
NPI:1467691691
Name:BALLANTINE, JILL FOSTER (PA)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:FOSTER
Last Name:BALLANTINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:JILL
Other - Middle Name:FOSTER
Other - Last Name:TROWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:8150 N CENTRAL EXPY
Mailing Address - Street 2:SUITE M1001
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-1815
Mailing Address - Country:US
Mailing Address - Phone:214-221-0022
Mailing Address - Fax:
Practice Address - Street 1:875 S COLLEGIATE DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-6305
Practice Address - Country:US
Practice Address - Phone:903-785-8857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0083AZMedicare PIN