Provider Demographics
NPI:1356381693
Name:LIEBNAU, JILL (CRNA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LIEBNAU
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8089 SUNDON DR
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144-9717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2409 CHERRY ST
Practice Address - Street 2:#305
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608
Practice Address - Country:US
Practice Address - Phone:419-251-3740
Practice Address - Fax:419-251-3859
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH192851174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2085952Medicaid
OH8222273Medicare PIN
OH430040703Medicare PIN
OH2085952Medicaid
OH8222272Medicare PIN