Provider Demographics
NPI:1306876818
Name:ENDICOTT, JILL A (NP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:ENDICOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-6400
Mailing Address - Fax:417-347-6404
Practice Address - Street 1:3202 MCINTOSH CIR
Practice Address - Street 2:SUITE LL03
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3646
Practice Address - Country:US
Practice Address - Phone:417-347-6400
Practice Address - Fax:417-347-6404
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004019593363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO192713OtherANTHEM
P00175249OtherRR MEDICARE
OK200034570AMedicaid
KS200265670AMedicaid
MO429313307Medicaid
P00175249OtherRR MEDICARE
MO822331431Medicare PIN