Provider Demographics
NPI:1720001167
Name:HAGEN, JILL (DPM)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:HAGEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4104
Mailing Address - Country:US
Mailing Address - Phone:201-568-6977
Mailing Address - Fax:201-568-7567
Practice Address - Street 1:363 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4104
Practice Address - Country:US
Practice Address - Phone:201-568-6977
Practice Address - Fax:201-568-7567
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD1961213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6198104Medicaid
NJ0933568OtherAETNA ID#
NJ0063356OtherGHI
NJ8748330OtherCIGNA ID #
NJP1023259OtherOXFORD HEALTH PLAN
NJJ32278OtherHEALTHNET
NJJ32278OtherHEALTHNET
NJ6198104Medicaid