Healthcare Provider Details

I. General information

NPI: 1043494578
Provider Name (Legal Business Name): JILL M CISAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 MIDWAY RD
MENASHA WI
54952-1115
US

IV. Provider business mailing address

1095 MIDWAY RD
MENASHA WI
54952-1115
US

V. Phone/Fax

Practice location:
  • Phone: 920-720-2300
  • Fax: 920-720-3806
Mailing address:
  • Phone: 920-720-3702
  • Fax: 920-720-3806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number966-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: