Provider Demographics
NPI:1821300849
Name:LEBLANC, JILL ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ELIZABETH
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MT
Mailing Address - Zip Code:59522-0705
Mailing Address - Country:US
Mailing Address - Phone:406-759-5194
Mailing Address - Fax:406-759-5105
Practice Address - Street 1:418 WEST MONROE AVENUE
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MT
Practice Address - Zip Code:59522
Practice Address - Country:US
Practice Address - Phone:406-759-5194
Practice Address - Fax:406-759-5105
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005862363A00000X
KYPA2985363A00000X
FLPA9114533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005862OtherGEORGIA LICENSE