Healthcare Provider Details

I. General information

NPI: 1578400636
Provider Name (Legal Business Name): JILL CHRISTINE NUEBEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 4TH ST SW
FOREST LAKE MN
55025-1536
US

IV. Provider business mailing address

5445 273RD ST
WYOMING MN
55092-9384
US

V. Phone/Fax

Practice location:
  • Phone: 651-982-8671
  • Fax:
Mailing address:
  • Phone: 651-982-8671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12002821
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: