Provider Demographics
NPI:1609071364
Name:LIGHTFOOT, JILL L (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:L
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:L
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2322 E KIMBERLY RD STE 100N
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-7207
Mailing Address - Country:US
Mailing Address - Phone:563-355-3376
Mailing Address - Fax:563-355-3840
Practice Address - Street 1:2322 E KIMBERLY RD STE 100N
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7207
Practice Address - Country:US
Practice Address - Phone:563-355-3376
Practice Address - Fax:563-355-3840
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR8125207R00000X, 207N00000X
IA39362207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine