Provider Demographics
NPI:1033622691
Name:POPPE MACKENZIE, JILL ALANE (JD, LSW)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ALANE
Last Name:POPPE MACKENZIE
Suffix:
Gender:F
Credentials:JD, LSW
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:ALANE
Other - Last Name:POPPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JD
Mailing Address - Street 1:7573 NORTHAM DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-8716
Mailing Address - Country:US
Mailing Address - Phone:952-240-6060
Mailing Address - Fax:
Practice Address - Street 1:955 CONGRESS PARK DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4009
Practice Address - Country:US
Practice Address - Phone:937-269-3047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1451150104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker