Provider Demographics
NPI:1790854370
Name:BREACH, JILL R (ARNP CNM FNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:BREACH
Suffix:
Gender:F
Credentials:ARNP CNM FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W TOWNLINE ST
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-1054
Mailing Address - Country:US
Mailing Address - Phone:641-782-7091
Mailing Address - Fax:641-782-3830
Practice Address - Street 1:601 ROSARY DR
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:IA
Practice Address - Zip Code:50841-1683
Practice Address - Country:US
Practice Address - Phone:641-322-5245
Practice Address - Fax:641-322-4687
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA081279363LF0000X
IAB081279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S72776Medicare UPIN