Provider Demographics
NPI:1154600906
Name:ROGERS, JILL ALLYN (PA-C)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ALLYN
Last Name:ROGERS
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 1:6608A WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-2052
Mailing Address - Country:US
Mailing Address - Phone:270-300-7544
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:270-300-7544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1098295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant