Provider Demographics
NPI:1881765071
Name:WEGNER, JILL (ACNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WEGNER
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6777 W MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3013
Mailing Address - Country:US
Mailing Address - Phone:248-325-1000
Mailing Address - Fax:
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:248-325-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195321363LA2100X
GARN190495363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4680917Medicaid
MI10-4689035Medicaid
MI10-4689044Medicaid
MI10-4689008Medicaid
MI11-4940999Medicaid
MI11-4941010Medicaid
MI11-4941029Medicaid
MI10-4689026Medicaid
MI11-4941000Medicaid
MI10-4689044Medicaid
MI11-4941010Medicaid