Healthcare Provider Details

I. General information

NPI: 1538920772
Provider Name (Legal Business Name): JILL MADISON RISLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 LAKE LANSING RD STE A
LANSING MI
48912-3752
US

IV. Provider business mailing address

12763 E GREENFIELD RD
GRAND LEDGE MI
48837-8944
US

V. Phone/Fax

Practice location:
  • Phone: 517-487-0128
  • Fax: 517-487-2639
Mailing address:
  • Phone: 517-449-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: