Healthcare Provider Details

I. General information

NPI: 1528588282
Provider Name (Legal Business Name): JILL J SMITH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 11/04/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W GOOD SAMARITAN DR
WARREN MN
56762-1412
US

IV. Provider business mailing address

300 W GOOD SAMARITAN DR
WARREN MN
56762-1412
US

V. Phone/Fax

Practice location:
  • Phone: 218-745-4211
  • Fax: 218-745-3254
Mailing address:
  • Phone: 218-745-4211
  • Fax: 218-745-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5209
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: