Provider Demographics
NPI:1891100970
Name:EASLEY, JILL TAYLOR
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:TAYLOR
Last Name:EASLEY
Suffix:
Gender:F
Credentials:
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 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:106 HIGHLAND WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6929
Practice Address - Country:US
Practice Address - Phone:601-200-4750
Practice Address - Fax:601-200-4740
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR877394363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily