Provider Demographics
NPI:1871538645
Name:FEEZELL, JILL A (DO)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:FEEZELL
Suffix:
Gender:F
Credentials:DO
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 8549
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0549
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:817-563-3699
Practice Address - Street 1:713 E ANDERSON ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5705
Practice Address - Country:US
Practice Address - Phone:817-596-8751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3537207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182748701Medicaid
TX0050NSOtherBCBS
TX8X8163OtherBCBS
TX612592Medicare PIN
TX0050NSOtherBCBS
8J8356Medicare PIN
TX8X8163OtherBCBS