Jill Michelle Dubravcic, FNP

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

AP5128 Issued in AZ

Practice address

710 N. Beaver St. #6
Flagstaff, AZ 86001

Phone

(928) 527-4325

Fax

(928) 773-0756

NPI assigned

Dec 5, 2013

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Jill Michelle Custer Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Oct 1, 2023 through Oct 1, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Revitalize Ketamine Clinic LLC

  • Multi-Specialty Clinic/Center
  • Flagstaff, AZ
  • NPI 1346911195
  NPD (past) Authorized official
• Az BD of Regents for on Behalf of Northern Az University

  • Primary Care Clinic/Center
  • Flagstaff, AZ
  • NPI 1891727863
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1386201600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1386201600000",
    "number": "1174954895",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "710 N. BEAVER ST. #6",
            "city": "FLAGSTAFF",
            "state": "AZ",
            "postal_code": "86001"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "710 N. BEAVER ST. #6",
            "city": "FLAGSTAFF",
            "state": "AZ",
            "postal_code": "86001",
            "telephone_number": "928-527-4325",
            "fax_number": "928-773-0756"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DUBRAVCIC",
        "first_name": "JILL",
        "middle_name": "MICHELLE",
        "name_prefix": "Mrs.",
        "credential": "FNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2013-12-05",
        "last_updated": "2013-12-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "AZ",
            "license": "AP5128",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JILL",
            "last_name": "CUSTER",
            "middle_name": "MICHELLE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Lauren Driebe, RPH
• Elizabeth Amelia Drum, RN, FNP-C
• Michael James Druschel, MD
• Amy Klein Duane, LCSW
• David G Dubner, PSYCHOLOGIST, PHD
• Phillip Casey Dubravcic, PMHNP
• Debbo Duclos, RN
• Madison Dugan
• Mikyla Belle Dugi
• Cassadi Duncan

• Nurse Practitioner in Flagstaff, AZ
• Providers in Flagstaff, AZ by specialty
• Nurse Practitioner in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.