Provider Demographics
NPI:1790265924
Name:BETHE, JILL MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:BETHE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 W SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-2342
Mailing Address - Country:US
Mailing Address - Phone:920-926-0101
Mailing Address - Fax:920-926-0060
Practice Address - Street 1:23 W SCOTT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2342
Practice Address - Country:US
Practice Address - Phone:920-926-0101
Practice Address - Fax:920-926-0060
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI142765163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty