Provider Demographics
NPI:1528588282
Name:SMITH, JILL J (NP-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W GOOD SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MN
Mailing Address - Zip Code:56762-1412
Mailing Address - Country:US
Mailing Address - Phone:218-745-4211
Mailing Address - Fax:218-745-3254
Practice Address - Street 1:300 W GOOD SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-1412
Practice Address - Country:US
Practice Address - Phone:218-745-4211
Practice Address - Fax:218-745-3254
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5209363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner