Provider Demographics
NPI:1225528664
Name:BANTAU, JILLENE MARIE
Entity Type:Individual
Prefix:
First Name:JILLENE
Middle Name:MARIE
Last Name:BANTAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILLENE
Other - Middle Name:MARIE
Other - Last Name:BRAUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:891 BELSLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1806 E FIR AVE STE 200
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-3921
Practice Address - Country:US
Practice Address - Phone:218-998-2992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist