Healthcare Provider Details

I. General information

NPI: 1932111911
Provider Name (Legal Business Name): JILL SCHULTZ O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15704 90TH ST NE SUITE 100
OTSEGO MN
55330-7448
US

IV. Provider business mailing address

15704 90TH ST NE SUITE 100
OTSEGO MN
55330-7448
US

V. Phone/Fax

Practice location:
  • Phone: 763-241-1090
  • Fax: 763-241-1091
Mailing address:
  • Phone: 763-241-1090
  • Fax: 763-241-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2919
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: