Provider Demographics
NPI:1235144031
Name:HASENBERG-GINDT, JILL ANNE (DO)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:ANNE
Last Name:HASENBERG-GINDT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:ANNE
Other - Last Name:HASENBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:4076 KOTHLOW AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-3090
Mailing Address - Country:US
Mailing Address - Phone:715-235-4537
Mailing Address - Fax:715-235-4535
Practice Address - Street 1:4076 KOTHLOW AVE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-3090
Practice Address - Country:US
Practice Address - Phone:715-235-4537
Practice Address - Fax:715-235-4535
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45018-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI105706OtherGMP
WI864421046263OtherPREFERRED ONE
WIW005284OtherCHAMPUS
WIP00311902OtherTRAVELERS RR
WIH77832Medicare UPIN
WI43503200Medicaid
WI11030-0007Medicare ID - Type Unspecified
WV43503200OtherWRISK
WIH77832OtherGROUP HEALTH
WI01-23529OtherMEDICA