Healthcare Provider Details

I. General information

NPI: 1780776559
Provider Name (Legal Business Name): JILL RENEE GOVEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1167 BORDER LN
WASHBURN ND
58577-4102
US

IV. Provider business mailing address

PO BOX 253
UNDERWOOD ND
58576-0253
US

V. Phone/Fax

Practice location:
  • Phone: 701-462-3389
  • Fax: 888-306-1159
Mailing address:
  • Phone: 701-442-3148
  • Fax: 888-306-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR25966
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: