Provider Demographics
NPI:1851309173
Name:ROBERTS, JILL ANN (APN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:APN
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:703 S FLEISHEL AVE STE 5000
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2015
Practice Address - Country:US
Practice Address - Phone:903-606-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP105649363L00000X
TX513933363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146749002Medicaid
TX146749003Medicaid
TX8Y9250OtherBCBS
TXTIN PLUS 096OtherTRICARE
TX8N8980OtherBCBS PROVIDER #
TX75-2616977-123OtherTRICARE
TX752616977096OtherTRICARE
TX146749003Medicaid
TX8L8535Medicare Oscar/Certification
TX75-2616977-123OtherTRICARE