Provider Demographics
NPI:1386951481
Name:NICKOLOFF, JILL RENAE (PA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:RENAE
Last Name:NICKOLOFF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-4227
Mailing Address - Country:US
Mailing Address - Phone:406-247-3350
Mailing Address - Fax:406-651-6406
Practice Address - Street 1:1020 N 27TH ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0760
Practice Address - Country:US
Practice Address - Phone:800-332-7156
Practice Address - Fax:406-247-6242
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant