Provider Demographics
NPI:1396852091
Name:SIMONS, JILL M (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:SIMONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:M
Other - Last Name:FUNK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:500 OSBORNE RD NE
Mailing Address - Street 2:310
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2765
Mailing Address - Country:US
Mailing Address - Phone:763-236-2700
Mailing Address - Fax:763-236-2710
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:310
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2765
Practice Address - Country:US
Practice Address - Phone:763-236-2700
Practice Address - Fax:763-236-2710
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44604174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN033093100Medicaid
MN033093100Medicaid