Provider Demographics
NPI:1013360718
Name:FENNER, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 LAKEWAY DR STE 10
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 LAKEWAY DR STE 10
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4456
Practice Address - Country:US
Practice Address - Phone:512-477-5445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76208101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor