Provider Demographics
NPI:1124455266
Name:ROUSH, JILLIAN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARIE
Last Name:ROUSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:MARIE
Other - Last Name:EMERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:6 DIANA LN
Practice Address - Street 2:
Practice Address - City:WEST HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-1210
Practice Address - Country:US
Practice Address - Phone:570-501-3760
Practice Address - Fax:570-501-3762
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056492363A00000X
PAOA003152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA326497F6KOtherMEDICARE PTAN