Provider Demographics
NPI:1407966765
Name:ROBERTSON, JILL LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:LYNN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 W HOMESTEAD ROAD, SUITE 30
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098
Mailing Address - Country:US
Mailing Address - Phone:435-615-0435
Mailing Address - Fax:435-604-0261
Practice Address - Street 1:2700 HOMESTEAD RD STE 30
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-4874
Practice Address - Country:US
Practice Address - Phone:435-615-0435
Practice Address - Fax:435-604-0261
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105610199934152W00000X
AR2555152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49941OtherBCBS
AR189694722Medicaid
AR49941Medicare ID - Type Unspecified
V07896Medicare UPIN