Provider Demographics
NPI:1619942521
Name:FISH, JILL L (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:L
Last Name:FISH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:L
Other - Last Name:MYATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2115 N KANSAS AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-2698
Mailing Address - Country:US
Mailing Address - Phone:402-463-6793
Mailing Address - Fax:402-463-6894
Practice Address - Street 1:2115 N KANSAS AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-2698
Practice Address - Country:US
Practice Address - Phone:402-463-6793
Practice Address - Fax:402-463-6894
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22834207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEI29813Medicare UPIN