Provider Demographics
NPI:1477955201
Name:VAN THOLEN, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:VAN THOLEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9495 KEILMAN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9295
Mailing Address - Country:US
Mailing Address - Phone:219-440-1232
Mailing Address - Fax:219-285-5687
Practice Address - Street 1:9495 KEILMAN ST STE 6
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9295
Practice Address - Country:US
Practice Address - Phone:219-440-1232
Practice Address - Fax:219-285-5687
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005137A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner