Provider Demographics
NPI:1043928856
Name:DAVIS, JILL SUSAN (MED, LBS)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:SUSAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 WHIPPLE WAY
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-1196
Mailing Address - Country:US
Mailing Address - Phone:215-692-0289
Mailing Address - Fax:
Practice Address - Street 1:1114 WHIPPLE WAY
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-1196
Practice Address - Country:US
Practice Address - Phone:215-692-0289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH004015101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor