Provider Demographics
NPI:1265592455
Name:CHURCHILL, JASON D (PA)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:D
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-6334
Mailing Address - Country:US
Mailing Address - Phone:618-997-4310
Mailing Address - Fax:618-998-9635
Practice Address - Street 1:1306 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1662
Practice Address - Country:US
Practice Address - Phone:618-273-3361
Practice Address - Fax:618-273-2504
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006030653363AM0700X
IL085-002808363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical