Provider Demographics
NPI:1588060750
Name:SIDANGE, JILL CHRISTINE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:CHRISTINE
Last Name:SIDANGE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 ELIZABETH WAY # 4
Mailing Address - Street 2:
Mailing Address - City:POTTERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48876-9545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 ELIZABETH WAY # 4
Practice Address - Street 2:
Practice Address - City:POTTERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48876-9545
Practice Address - Country:US
Practice Address - Phone:517-505-2749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704265752363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704265752OtherN P SPECIALTY CERTIFICATE