Provider Demographics
NPI:1316078488
Name:FLICKINGER, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FLICKINGER
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 1:15871 W LAUREL CANYON CT
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4517
Mailing Address - Country:US
Mailing Address - Phone:623-523-8640
Mailing Address - Fax:623-523-8611
Practice Address - Street 1:17032 W SURPRISE FARMS LOOP S
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-1581
Practice Address - Country:US
Practice Address - Phone:623-523-8640
Practice Address - Fax:623-523-8611
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN102211163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ856239Medicaid