Healthcare Provider Details

I. General information

NPI: 1891788261
Provider Name (Legal Business Name): JILL A NOACK PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MICHIGAN ST NE SUITE 3100
GRAND RAPIDS MI
49503-2562
US

IV. Provider business mailing address

710 KENMOOR AVE SE SUITE 100
GRAND RAPIDS MI
49546-2379
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-9800
  • Fax: 616-954-2116
Mailing address:
  • Phone: 616-954-9800
  • Fax: 616-954-0659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001749
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601001749
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601001749
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: