Basic Information
Provider Information | |||||||||
NPI: | 1104811215 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | JILL | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 779 | ||||||||
Address2: |   | ||||||||
City: | TAWAS CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 487640779 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8552989888 | ||||||||
FaxNumber: | 9894973162 | ||||||||
Practice Location | |||||||||
Address1: | 1212 W SAGINAW RD | ||||||||
Address2: |   | ||||||||
City: | VASSAR | ||||||||
State: | MI | ||||||||
PostalCode: | 487689483 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9898235020 | ||||||||
FaxNumber: | 9898237881 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2005 | ||||||||
LastUpdateDate: | 04/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704173083 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | M10200335 | 01 | MI | TRICARE | OTHER | 150533 | 01 | MI | MEDICAID-GREATLAKES | OTHER | 0877585 | 01 | MI | BCBSMI | OTHER | 4708328 | 05 | MI |   | MEDICAID |