Provider Demographics
NPI:1912041096
Name:RUDMAN, JILL C (PHD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:C
Last Name:RUDMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2665 S MOORLAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-2900
Mailing Address - Country:US
Mailing Address - Phone:414-475-1896
Mailing Address - Fax:414-988-9764
Practice Address - Street 1:2665 S MOORLAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151
Practice Address - Country:US
Practice Address - Phone:414-475-1896
Practice Address - Fax:414-988-9764
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2172-057103TC0700X
WI1095559103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39679600Medicaid