Healthcare Provider Details

I. General information

NPI: 1093975039
Provider Name (Legal Business Name): JILL ANNE FERGUSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 MISSOURI AVE
SHREVEPORT LA
71109-4327
US

IV. Provider business mailing address

PO BOX 731280
DALLAS TX
75373-1280
US

V. Phone/Fax

Practice location:
  • Phone: 318-621-8820
  • Fax: 318-212-4189
Mailing address:
  • Phone: 318-841-9526
  • Fax: 318-841-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number11013817A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number205414
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: