Basic Information
| Provider Information | |||||||||
| NPI: | 1265592455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHURCHILL | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 LINCOLN DR | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629486334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189974310 | ||||||||
| FaxNumber: | 6189989635 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | ELDORADO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629301662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182733361 | ||||||||
| FaxNumber: | 6182732504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 02/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2006030653 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 085-002808 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.