Provider Demographics
NPI:1356618870
Name:KANG, JILL CATHERINE (DPM)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:CATHERINE
Last Name:KANG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:GREENLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-253-5300
Mailing Address - Fax:701-253-5402
Practice Address - Street 1:2430 20TH ST SW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401
Practice Address - Country:US
Practice Address - Phone:701-253-5300
Practice Address - Fax:701-253-5402
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002296213E00000X
ND64213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17780Medicaid
NDN718758Medicare PIN