Provider Demographics
NPI:1306456256
Name:WILCKEN, JILL MARIE
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:WILCKEN
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 1:26122 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9836
Mailing Address - Country:US
Mailing Address - Phone:320-469-4771
Mailing Address - Fax:
Practice Address - Street 1:525 MAIN ST W
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MN
Practice Address - Zip Code:56352-1043
Practice Address - Country:US
Practice Address - Phone:320-256-4228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily