Provider Demographics
NPI:1932111911
Name:SCHULTZ, JILL (OD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15704 90TH ST NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-7448
Mailing Address - Country:US
Mailing Address - Phone:763-241-1090
Mailing Address - Fax:763-241-1091
Practice Address - Street 1:15704 90TH ST NE
Practice Address - Street 2:SUITE 100
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-7448
Practice Address - Country:US
Practice Address - Phone:763-241-1090
Practice Address - Fax:763-241-1091
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN150147000Medicaid
MN410002180Medicare ID - Type UnspecifiedMEDICARE
MN150147000Medicaid