Provider Demographics
NPI:1124298948
Name:ANSPACH, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:ANSPACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11185 E SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DELTON
Mailing Address - State:MI
Mailing Address - Zip Code:49046-9406
Mailing Address - Country:US
Mailing Address - Phone:269-615-6848
Mailing Address - Fax:
Practice Address - Street 1:11185 E SHORE DR
Practice Address - Street 2:
Practice Address - City:DELTON
Practice Address - State:MI
Practice Address - Zip Code:49046-9406
Practice Address - Country:US
Practice Address - Phone:269-615-6848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007021174400000X
CAOT 9870174400000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist