1609303379 NPI number — JILL DENISE DIERKS FNP

Table of content: JILL DENISE DIERKS FNP (NPI 1609303379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609303379 NPI number — JILL DENISE DIERKS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIERKS
Provider First Name:
JILL
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609303379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2405 ROCK ISLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OELWEIN
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50662-3102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-283-2651
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9947 W HAPPY VALLEY RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85383-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-434-5748
Provider Business Practice Location Address Fax Number:
623-566-9665
Provider Enumeration Date:
05/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  TAP10109 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: N/A . This is a "N/A" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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