Provider Demographics
NPI:1891972584
Name:BRAATEN, JILL M (DC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:BRAATEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 1ST STREET SOUTH
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387
Mailing Address - Country:US
Mailing Address - Phone:320-240-6561
Mailing Address - Fax:
Practice Address - Street 1:750 1ST STREET SOUTH
Practice Address - Street 2:SUITE 103
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387
Practice Address - Country:US
Practice Address - Phone:320-240-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4986111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350004055OtherMEDICARE PTAN
MN36M21BROtherBLUE CROSS BLUE SHIELD PROVIDER ID