Provider Demographics
NPI:1679980783
Name:VAN OTTERLOO, JILL (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:VAN OTTERLOO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S ILLINOIS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-428-3041
Mailing Address - Fax:641-428-3059
Practice Address - Street 1:635 E US HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:IA
Practice Address - Zip Code:50436-1028
Practice Address - Country:US
Practice Address - Phone:641-585-2904
Practice Address - Fax:641-585-5417
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant