Provider Demographics
NPI:1003916149
Name:GOLDSWORTHY, JILL MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:GOLDSWORTHY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8008 GINA DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-2510
Mailing Address - Country:US
Mailing Address - Phone:608-347-2776
Mailing Address - Fax:
Practice Address - Street 1:10045 W LISBON AVE
Practice Address - Street 2:SUITE 221
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2446
Practice Address - Country:US
Practice Address - Phone:414-358-7146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN180241041C0700X
MO20050410201041C0700X
WI7336-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43716200Medicaid
MN836118000Medicaid
WI39-1850832OtherFEDERAL TAX ID