Provider Demographics
NPI:1386817021
Name:WITTE, JILL M (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:WITTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:M
Other - Last Name:FRISQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1346 E GREEN BAY ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2210
Mailing Address - Country:US
Mailing Address - Phone:715-526-6244
Mailing Address - Fax:
Practice Address - Street 1:1346 E GREEN BAY ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2210
Practice Address - Country:US
Practice Address - Phone:715-526-6244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI123577-030163W00000X
WI3442-33363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3442-33OtherWISCONSIN LICENSE
WI123577-30OtherWISCONSIN RN LICENSE
WI123577-30OtherWISCONSIN RN LICENSE
WI3442-33OtherWISCONSIN LICENSE
WIK400195208Medicare Oscar/Certification
WI3442-33OtherWISCONSIN LICENSE
WI000075Medicare Oscar/Certification
WI123577-30OtherWISCONSIN RN LICENSE