Provider Demographics
NPI:1649538588
Name:MONROE, JILL MARIE (LMT)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:MARIE
Last Name:MONROE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16435 E SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8540
Mailing Address - Country:US
Mailing Address - Phone:907-315-6658
Mailing Address - Fax:
Practice Address - Street 1:1751 E GARDNER WAY STE E
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6564
Practice Address - Country:US
Practice Address - Phone:907-315-6658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-29
Last Update Date:2012-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK951984172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker