Provider Demographics
NPI:1679963706
Name:LOTZ, JILL R (APNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:LOTZ
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:WALLERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:12225 71ST ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7320
Practice Address - Country:US
Practice Address - Phone:776-667-2238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6197363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100042950Medicaid