Basic Information
| Provider Information | |||||||||
| NPI: | 1790265924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETHE | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 W SCOTT ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549352342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209260101 | ||||||||
| FaxNumber: | 9209260060 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 W SCOTT ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549352342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209260101 | ||||||||
| FaxNumber: | 9209260060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2018 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 142765 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.