Provider Demographics
NPI:1255376190
Name:HENRITZE, JILL F (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:F
Last Name:HENRITZE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-4143
Mailing Address - Country:US
Mailing Address - Phone:276-469-8899
Mailing Address - Fax:276-469-8904
Practice Address - Street 1:811 STATE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-4143
Practice Address - Country:US
Practice Address - Phone:276-469-8899
Practice Address - Fax:276-469-8904
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255376190Medicaid
TN3661425Medicaid
TNPA0001029OtherLICENSE
TN103I978625Medicare PIN
VA1255376190Medicaid