Provider Demographics
NPI:1942301387
Name:HENRY, JILL (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:HENRY
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 1:3156 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-773-9772
Mailing Address - Fax:541-773-1113
Practice Address - Street 1:3156 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-773-9772
Practice Address - Fax:541-773-1113
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00571363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORQ09316Medicare UPIN
ORR130347Medicare PIN