Provider Demographics
NPI:1891788261
Name:NOACK, JILL A (PA C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:NOACK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 KENMOOR AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2379
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:616-954-0659
Practice Address - Street 1:145 MICHIGAN ST NE
Practice Address - Street 2:SUITE 3100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2562
Practice Address - Country:US
Practice Address - Phone:616-954-9800
Practice Address - Fax:616-954-2116
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001749363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C91143OtherBCBSM
MICA3050OtherRAILROAD MEDICARE
MI0C91143OtherBCBSM
MI0C91143OtherBCBSM
383148262OtherEIN-HEALTHCARE MIDWEST
7N66660011Medicare PIN
MI0N83160003Medicare PIN