Healthcare Provider Details

I. General information

NPI: 1427042019
Provider Name (Legal Business Name): JILL MARIE ENGLUND PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 DUPONT AVE SO SUITE 425
BLOOMINGTON MN
55431-3100
US

IV. Provider business mailing address

9801 DUPONT AVE SO SUITE 425
BLOOMINGTON MN
55431-3100
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-5800
  • Fax:
Mailing address:
  • Phone: 952-888-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9928
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: