Basic Information
| Provider Information | |||||||||
| NPI: | 1144390394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLE | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | ALISON | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379147054 | ||||||||
| FaxNumber: | 9375227685 | ||||||||
| Practice Location | |||||||||
| Address1: | 1141 N MONROE DR | ||||||||
| Address2: | |||||||||
| City: | XENIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453851619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373723638 | ||||||||
| FaxNumber: | 9373723642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50000288 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 50000288 | 01 | OH | OHIO LICENSE | OTHER |