Provider Demographics
NPI:1609568625
Name:PREZKOP, JILLIAN (PA)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:PREZKOP
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:570-808-7916
Mailing Address - Fax:570-808-6006
Practice Address - Street 1:1155 EAST MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7906
Practice Address - Country:US
Practice Address - Phone:570-808-7916
Practice Address - Fax:570-808-6006
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMP8302060363A00000X
PAMA066237363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant