Healthcare Provider Details

I. General information

NPI: 1053657114
Provider Name (Legal Business Name): JILL CHRISTINE PATE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 S PEACHTREE ST
JASPER TX
75951-4916
US

IV. Provider business mailing address

1276 S PEACHTREE ST
JASPER TX
75951-4916
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-5701
  • Fax:
Mailing address:
  • Phone: 409-384-5701
  • Fax: 409-384-4238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number651764
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: