Basic Information
| Provider Information | |||||||||
| NPI: | 1497297675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S PARK ST STE A | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082602900 | ||||||||
| FaxNumber: | 6082603455 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S PARK ST STE A | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082602900 | ||||||||
| FaxNumber: | 6082603455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2016 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 8071-033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1497297675 | 05 | WI | MEDICAID |