Provider Demographics
NPI:1023056330
Name:KLIETHERMES, JILL A (APRN, BC, FNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:KLIETHERMES
Suffix:
Gender:F
Credentials:APRN, BC, FNP
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:A
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-5747
Mailing Address - Fax:573-636-9756
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-5747
Practice Address - Fax:573-635-5264
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO142074363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ70423Medicare UPIN