Provider Demographics
NPI:1265433924
Name:HAVEN, JILL MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:MARIE
Last Name:HAVEN
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 1:111 E 4TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6241
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:
Practice Address - Street 1:5353 W HIGHWAY 290 STE 102
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-0046
Practice Address - Country:US
Practice Address - Phone:512-899-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7500TG152WC0802X, 152W00000X
MI4901004284152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN93570002Medicare ID - Type Unspecified
MIV04374Medicare UPIN