Provider Demographics
NPI:1275939621
Name:DR. JILL ANDERSON & ASSOCIATES, LLC
Entity Type:Organization
Organization Name:DR. JILL ANDERSON & ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-340-0496
Mailing Address - Street 1:422 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-4924
Mailing Address - Country:US
Mailing Address - Phone:920-235-8500
Mailing Address - Fax:920-303-5547
Practice Address - Street 1:422 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4924
Practice Address - Country:US
Practice Address - Phone:920-235-8500
Practice Address - Fax:920-303-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2651152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU67383Medicare UPIN