Provider Demographics
NPI:1114967403
Name:KRUSE, JILL D (DO)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:D
Last Name:KRUSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKING
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2450
Mailing Address - Country:US
Mailing Address - Phone:605-697-9500
Mailing Address - Fax:605-697-6939
Practice Address - Street 1:400 22ND AVE
Practice Address - Street 2:
Practice Address - City:BROOKING
Practice Address - State:SD
Practice Address - Zip Code:57006-2450
Practice Address - Country:US
Practice Address - Phone:605-697-9500
Practice Address - Fax:605-697-6939
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49795-021207Q00000X
SD7282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5613110Medicaid