Provider Demographics
NPI:1043252190
Name:WALL, JILL SUZANNE (PA)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:SUZANNE
Last Name:WALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:SUZANNE
Other - Last Name:DAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:917 SPRINGTIME TRL
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:TN
Mailing Address - Zip Code:37865-3256
Mailing Address - Country:US
Mailing Address - Phone:865-789-1595
Mailing Address - Fax:
Practice Address - Street 1:742 MIDDLECREEK RD
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5047
Practice Address - Country:US
Practice Address - Phone:865-446-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00285556OtherRRGA
TN4095095OtherBLUE CROSS
TN3663358Medicaid
TN3663358Medicaid