Provider Demographics
NPI:1184929705
Name:SKINNER, JILL S (OD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:S
Last Name:SKINNER
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 1:279 MATTHEW ST
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1417
Mailing Address - Country:US
Mailing Address - Phone:203-232-5948
Mailing Address - Fax:
Practice Address - Street 1:279 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1417
Practice Address - Country:US
Practice Address - Phone:203-232-5948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002562152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist