Provider Demographics
NPI:1528058443
Name:INGELSE, JILL C (OD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:C
Last Name:INGELSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13114 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2439
Mailing Address - Country:US
Mailing Address - Phone:708-388-1228
Mailing Address - Fax:708-388-1696
Practice Address - Street 1:13114 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2439
Practice Address - Country:US
Practice Address - Phone:708-388-1228
Practice Address - Fax:708-810-9726
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-22
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009096152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009096Medicaid
IL1634291OtherBLUE CROSS BLUE SHIELD
IL1290690001Medicare NSC
ILDR0185Medicare PIN
IL553460Medicare ID - Type Unspecified
ILU71976Medicare UPIN