Healthcare Provider Details

I. General information

NPI: 1689237638
Provider Name (Legal Business Name): JILL WACKLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 GREENBRIAR LN
BUFFALO MN
55313-2368
US

IV. Provider business mailing address

2404 GREENBRIAR LN
BUFFALO MN
55313-2368
US

V. Phone/Fax

Practice location:
  • Phone: 763-923-5254
  • Fax:
Mailing address:
  • Phone: 763-923-5254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number2471754
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: