Healthcare Provider Details

I. General information

NPI: 1760696967
Provider Name (Legal Business Name): JENNIFER ANN FILLAUS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/17/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

YANKTON MEDICAL CLINIC P.C. 1104 W 8TH STREET
YANKTON SD
57078-3306
US

IV. Provider business mailing address

1104 W 8TH ST
YANKTON SD
57078-3306
US

V. Phone/Fax

Practice location:
  • Phone: 605-665-7841
  • Fax: 605-665-0546
Mailing address:
  • Phone: 605-665-7841
  • Fax: 605-665-8337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number810
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14278
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: