Provider Demographics
NPI:1023246873
Name:POWNELL, JILL ANITA (OD)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:ANITA
Last Name:POWNELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:ANITA
Other - Last Name:SANDBAKKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 19TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-3938
Mailing Address - Country:US
Mailing Address - Phone:057-533-9376
Mailing Address - Fax:605-753-0472
Practice Address - Street 1:22 19TH ST SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3938
Practice Address - Country:US
Practice Address - Phone:605-753-3937
Practice Address - Fax:605-753-0472
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002458152W00000X
SDT681152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA421499499Medicaid
SD4977608OtherBCBS SD
SDS112121OtherMEDICARE PIN