Provider Demographics
NPI:1013044163
Name:KOESKE, JILL ALLEN (RD)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:ALLEN
Last Name:KOESKE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8957 WOOSTER CT
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-4513
Mailing Address - Country:US
Mailing Address - Phone:317-403-1247
Mailing Address - Fax:
Practice Address - Street 1:8957 WOOSTER CT
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-4513
Practice Address - Country:US
Practice Address - Phone:317-403-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000621A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered