Provider Demographics
NPI:1043345697
Name:DODGE, JILL KATHLEEN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:KATHLEEN
Last Name:DODGE
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 1:3990 OLD TOWN AVE
Mailing Address - Street 2:STE 209A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110
Mailing Address - Country:US
Mailing Address - Phone:619-615-5065
Mailing Address - Fax:619-294-9181
Practice Address - Street 1:3990 OLD TOWN AVE
Practice Address - Street 2:STE 209A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2967
Practice Address - Country:US
Practice Address - Phone:619-615-5065
Practice Address - Fax:619-294-9181
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS5760104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SW5760AMedicare ID - Type Unspecified