Provider Demographics
NPI:1083664452
Name:STEPHENS, JILL A (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 CAMDEN LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3013
Mailing Address - Country:US
Mailing Address - Phone:262-784-0544
Mailing Address - Fax:
Practice Address - Street 1:2906 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3732
Practice Address - Country:US
Practice Address - Phone:414-385-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34173-202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31944200Medicaid
WI31944200Medicaid