Provider Demographics
NPI:1831290402
Name:STEPHENSON-MCCOLE, JILL L (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:L
Last Name:STEPHENSON-MCCOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-645-0000
Mailing Address - Fax:517-645-4559
Practice Address - Street 1:2040 AURELIUS RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1367
Practice Address - Country:US
Practice Address - Phone:517-694-2217
Practice Address - Fax:517-694-2655
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13334867Medicaid
CO13334867Medicaid