Provider Demographics
NPI:1730673435
Name:BEDNAR, JILL LORRAINE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:LORRAINE
Last Name:BEDNAR
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18500 285TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAFER
Mailing Address - State:MN
Mailing Address - Zip Code:55074-9768
Mailing Address - Country:US
Mailing Address - Phone:651-500-4420
Mailing Address - Fax:
Practice Address - Street 1:740 MAPLE DR
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9125
Practice Address - Country:US
Practice Address - Phone:715-483-9824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25172255A2300X
WI1490-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer