Basic Information
Provider Information | |||||||||
NPI: | 1922324714 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRUGE | ||||||||
FirstName: | JILL | ||||||||
MiddleName: | HUCKABEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUCKABEE | ||||||||
OtherFirstName: | JILL | ||||||||
OtherMiddleName: | ALLISON | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708166038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2257655727 | ||||||||
FaxNumber: | 2257659196 | ||||||||
Practice Location | |||||||||
Address1: | 7855 JEFFERSON HWY | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708091206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2252143199 | ||||||||
FaxNumber: | 2252148011 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2010 | ||||||||
LastUpdateDate: | 12/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD.204924 | LA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207N00000X | LA.204924 | LA | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 2106538 | 05 | LA |   | MEDICAID |