Provider Demographics
NPI:1619143146
Name:SHORT, JILL DELANA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MISS
First Name:JILL
Middle Name:DELANA
Last Name:SHORT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1470
Mailing Address - Country:US
Mailing Address - Phone:606-638-4595
Mailing Address - Fax:
Practice Address - Street 1:412 N LOCK AVE
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1115
Practice Address - Country:US
Practice Address - Phone:606-638-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA442363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical