Provider Demographics
NPI:1578921441
Name:GETTLE, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:GETTLE
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 1:28455 HAGGERTY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2982
Mailing Address - Country:US
Mailing Address - Phone:248-699-2389
Mailing Address - Fax:
Practice Address - Street 1:28455 HAGGERTY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2982
Practice Address - Country:US
Practice Address - Phone:248-699-2389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI810980133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered