Basic Information
| Provider Information | |||||||||
| NPI: | 1639250624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROCTOR | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 SPRINGER DR | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601486413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157448554 | ||||||||
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| Practice Location | |||||||||
| Address1: | 781 WEATHERLY DR APT C | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370438954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314445040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 7799 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 7799 | 01 | TN | APN LICENSE | OTHER | MP1412725 | 01 | TN | DEA LICENSE | OTHER |