Provider Demographics
NPI:1033792700
Name:ANDERSON, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:ANDERSON
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 1:106 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:OH
Mailing Address - Zip Code:43084-9762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:OH
Practice Address - Zip Code:43084-9762
Practice Address - Country:US
Practice Address - Phone:614-327-0517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty