Provider Demographics
NPI:1306308275
Name:CERETTO, JILL NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:NICOLE
Last Name:CERETTO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:NICOLE
Other - Last Name:MANSKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:141 MARKET PL STE 203
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2060
Mailing Address - Country:US
Mailing Address - Phone:618-398-4118
Mailing Address - Fax:
Practice Address - Street 1:141 MARKET PL STE 203
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2060
Practice Address - Country:US
Practice Address - Phone:618-398-4118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001820156FX1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric Assistant