Provider Demographics
NPI:1871510891
Name:UNDERBERG, JILL M (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:M
Last Name:UNDERBERG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 N 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1510
Mailing Address - Country:US
Mailing Address - Phone:414-258-1777
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:PRIMARY CARE YELLOW CLINIC
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:414-389-4198
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12258-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI89455OtherVA#