Provider Demographics
NPI:1215152145
Name:WAHL, JILL MARIE (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:WAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 W SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-5603
Mailing Address - Country:US
Mailing Address - Phone:309-472-7295
Mailing Address - Fax:
Practice Address - Street 1:1098 1350TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-5094
Practice Address - Country:US
Practice Address - Phone:217-735-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F85330Medicare UPIN