Provider Demographics
NPI:1336490218
Name:WENANDE, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WENANDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7709 W 53RD ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-7546
Mailing Address - Country:US
Mailing Address - Phone:605-328-1630
Mailing Address - Fax:605-328-1640
Practice Address - Street 1:1210 W 18TH ST
Practice Address - Street 2:SUITE LL01
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4647
Practice Address - Country:US
Practice Address - Phone:605-328-1860
Practice Address - Fax:605-328-1640
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist