Provider Demographics
NPI:1558542761
Name:LEBLANC, JILL MARGARET (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARGARET
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:L
Other - Last Name:CROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-579-3203
Mailing Address - Fax:
Practice Address - Street 1:20414 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3250
Practice Address - Country:US
Practice Address - Phone:602-849-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4664363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1165468Medicaid
LA3A578Medicare UPIN
LAP00916179Medicare PIN
LA3A5787460Medicare PIN