Provider Demographics
NPI:1154306686
Name:HARTLEY, JILL MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:HARTLEY
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 1:1375 NW KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-2242
Mailing Address - Country:US
Mailing Address - Phone:541-383-5958
Mailing Address - Fax:541-383-3016
Practice Address - Street 1:1375 NW KINGSTON AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-2242
Practice Address - Country:US
Practice Address - Phone:541-383-5958
Practice Address - Fax:541-383-3016
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant