Basic Information
| Provider Information | |||||||||
| NPI: | 1295908259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OBRIEN | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT MORRIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610541646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157346061 | ||||||||
| FaxNumber: | 8157349021 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 S HENNEPIN AVE | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610213013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152858520 | ||||||||
| FaxNumber: | 8152858903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2008 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209-004480 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | F400458270 | 01 | IL | MEDICARE PTAN | OTHER |