Provider Demographics
NPI:1164427076
Name:SMITH, JILL R (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-331-3402
Mailing Address - Fax:812-355-6549
Practice Address - Street 1:550 LANDMARK AVE.
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-0550
Practice Address - Country:US
Practice Address - Phone:812-331-3402
Practice Address - Fax:812-355-6549
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001392A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200395770Medicaid
IN200395770Medicaid
INP76301Medicare UPIN
INM400022242Medicare PIN