Provider Demographics
NPI:1619951126
Name:PEASE, JILL C (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:PEASE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:C
Other - Last Name:BUCKLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:3554 PROMENADE PKWY
Mailing Address - Street 2:SUITE H
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-8417
Mailing Address - Country:US
Mailing Address - Phone:765-471-1100
Mailing Address - Fax:
Practice Address - Street 1:3554 PROMENADE PKWY
Practice Address - Street 2:SUITE H
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-8417
Practice Address - Country:US
Practice Address - Phone:765-471-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000824A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000540149OtherANTHEM PROVIDER NUMBER
IN815460NNNNMedicare PIN
INP00439685Medicare PIN