Provider Demographics
NPI:1689237638
Name:WACKLER, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WACKLER
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 1:2404 GREENBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2368
Mailing Address - Country:US
Mailing Address - Phone:763-923-5254
Mailing Address - Fax:
Practice Address - Street 1:2404 GREENBRIAR LN
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2368
Practice Address - Country:US
Practice Address - Phone:763-923-5254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2471754163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management