Provider Demographics
NPI:1124756002
Name:ULLMER, JILL MARIE
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:ULLMER
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:N5972 VINE RD
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:WI
Mailing Address - Zip Code:54165-8148
Mailing Address - Country:US
Mailing Address - Phone:920-277-6989
Mailing Address - Fax:
Practice Address - Street 1:801 HOFFMAN RD STE 106
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-1462
Practice Address - Country:US
Practice Address - Phone:920-277-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI717-403174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist