Provider Demographics
NPI:1548216971
Name:BETHLEHEM, JILL BETHANY (PA)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:BETHANY
Last Name:BETHLEHEM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:BETHANY
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:220 CAMPUS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2889
Mailing Address - Country:US
Mailing Address - Phone:540-536-0307
Mailing Address - Fax:540-536-0235
Practice Address - Street 1:607 E JUBAL EARLY DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-536-2232
Practice Address - Fax:540-536-2205
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2202363A00000X
VA0110006313363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ21440Medicare UPIN
PA081969Medicare ID - Type Unspecified