Healthcare Provider Details

I. General information

NPI: 1588185102
Provider Name (Legal Business Name): JILL M HAASE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL M KOCH

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

IV. Provider business mailing address

111 E WISCONSIN AVE STE 2000
MILWAUKEE WI
53202-4809
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6720
  • Fax: 414-290-6755
Mailing address:
  • Phone: 414-290-6720
  • Fax: 414-290-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4043-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: